Download Vaginal Reconstruction

VAGINAL RECONSTRUCTION
Embryology
 During fetal development in females, the paramesonephric (Mullerian) ducts mature
into the Fallopian tubes, uterus, cervix, and upper third of the vagina.
 The lower part of the vagina is derived from the urogenital sinus, which comes from
the perineum. In males, the Mullerian ducts regress under the influence of Mullerian
Inhibitory Factor from the developing testes.
 Mesonephric ducts and tubules degenerate in the absence of MIF and testosterone
Anatomy
 external genitalia composed of the clitoris, labia majora and labia minora, and vagina.
 Internal iliac artery
Anterior division
Umbilical artery
Superior vesical artery
Obturator artery
Uterine artery
Vaginal artery
Inferior vesical artery (male)
Middle rectal artery
Internal pudendal artery
Inferior gluteal artery
Posterior division
Iliolumbar artery
Lateral sacral artery
Superior gluteal artery
Perineum
 Blood supply
Main supply internal pudendal artery
Branches
Inferior rectal
Transverse perineal
Perineal artery (superficial/deep)  posterior labial/scrotal
Dorsal artery to clitoris/penis
Also deep and superficial external pudendal arteries (branches of CFA)
 perineum can be conveniently conceptualized as being composed of anterior and
posterior triangles divided by a line connecting the 2 ischial tuberosities. Superior
apex = pubic symphysis and inferior apex = coccyx
 Anterior triangle
o perineal membrane which is pierced by the genital hiatus and the urethra,
separates the anterior triangles into deep and superficial compartments.
 Superficial anterior triangle
o immediately under the skin of the labium majus is a digital extension of
the superficial fatty layer (Camper fascia) of the lower abdominal wall.
o Next is a layer of dense connective tissue, ie, the Colles fascia. This layer,
which is a continuation of the Scarpa fascia of the anterior abdominal
wall, extends from the lateral aspect of the bulbocavernosus muscle to the
ischiopubic ramus and inserts in the connective tissue of the inguinal
ligament anteriorly and the fascia of the posterior margin of the anterior
perineal triangle.
Vagina
 fibromuscular tube lined with stratified nonkeratinised squamous epithelium.
 inclined postero-superiorly
 length is 7.5 cm along anterior wall and 9 cm along posterior wall.
 There are no glands in the mucous membrane
 lubricated by mucus derived from cervical glands.
Pathology
1. Congenital anomalies
a. Complete vaginal reconstruction
i.
Uterovaginal agenesis or the complete form of the MRKH syndrome
ii.
Intersex conditions (ie testicular feminization)
b. Partial vaginal reconstruction
i.
Distal or proximal vaginal atresia or incomplete forms of the MRKH
syndrome
ii.
Intersex conditions (congenital adrenal hyperplasia, androgen
insensitivity syndrome, mixed gonadal dysgenesis)
2. Acquired vaginal defects
a. Colpocleisis (pharmacologically or radiation-induced)
b. Vaginal defects secondary to cancer, trauma ie child birth, infection, chronic
inflammatory disease or iatrogenesis
Congenital Syndromes
1. Mayer-Rokitansky-Küster-Hauser syndrome
 vaginal atresia with other variable müllerian (ie, paramesonephric) duct
abnormalities
 due to failure of the caudal development of the müllerian ducts
 usually remains undetected until the patient presents with primary amenorrhea
despite normal sexual female development.
 MRK is the second most common cause of primary amenorrhea.
 Usually sporadic
 1 per 4000-5000 female births
 normal vulva with an absent vagina, or a vagina that is represented by a shallow
dimple
 uterus and cervix are usually hypoplastic. The ovaries and their functions are
normal; secondary sexual characters are also normal.
 present with cyclical abdominal pain and increasing abdominal mass due to
accumulation of menstrual products.
 Renal anomalies are seen in 34–49% and skeletal anomalies in 10–15% (KlippelFeil)
2. Intersex conditions
 Classifications based on the differentiation of the gonad:
1. Female pseudohermaphrodite - Two ovaries
a. Congenital adrenal hyperplasia
2. Male pseudohermaphrodite - Two testes
a. Androgen insensitivity
b. alpha reductase deficiency
3. True hermaphrodite - Ovary and/or testis and/or ovotestis
a. Mosaicism, translocation Y gene
4. Mixed gonadal dysgenesis - Testis plus streak gonad
5. Pure gonadal dysgenesis - Bilateral streak gonads
Management
 With congenital anomalies, gender assignment is a complex issue and should be
done in a multidisciplinary setting
Define the defect
1. Vulva
2. Vagina
3. Perineum
Clitoroplasty
 Not often performed - a constructed clitoris is usually unsatisfactory in shape
 In transgender ops, the penile glans are used.
Vulvoplasty
 Usually performed with local flaps +/- tissue expansion.
 Mons pubis pedicled flap (1994)
Vaginoplasty
 Ideal reconstruction
1. located at an appropriate place and directed postero superiorly
2. adequate width(4cm), depth (6-10cm)
3. lined by elastile tissue either by full thickness skin or mucosa
4. neither permanently moist nor malodours
5. hairless sensate at least at the introitus level
 skin is associated with dryness and maceration, hair growth and contracture.
Frank's technique (1938)
 nonsurgical serial perineal dilatation
 Patients apply progressive pressure to the perineum using a bicycle-seat stool to hold a
dilator in place.
 success depends on the presence of at least a vaginal dimple and requires a highly
motivated patient who, wishing to avoid extensive surgical procedures, is willing to
continue long-term dilation. Problems of stenosis and dyspareunia have made this
option less attractive for many patients.
 Because this technique is self-administered, compliance is often poor in patients with a
vaginal dimple or no vagina because these patients experience discomfort and abandon
the dilator.
 Advantages is that it is lined with vaginal mucosa, under hormonal control and is
innervation. Urinary and rectal fistulas are rare.
Abbe-McIndoe Inlay Graft Method (1898-1938)
 A neovaginal cavity is created between rectum and bladder and lined with splitthickness skin graft held in place with a stent. The main problem is the strong
tendency of the graft to contract
 requires the constant use of a mold to prevent stricture.
 3 months of 24 hour stenting and nightly for another 3months. Not only is this
inconvenient, but also complications may occur, including rectovaginal fistula or
intraperitoneal penetration of the mold
 Variants: full-thickness skin grafts , or with amnion, buccal mucosa.
 Stents(Mold): Many stents have been described, including the balsa stent, over which
the graft is sewn and inserted into the vaginal pocket, silicone foam molds, foam
rubber stents, which are carved from blocks and placed in condoms, Surgi-Stuf- or
gauze-filled condoms, inflatable vaginal stents with internal drains, vacuum
expandable condom and jelonet/gauze wrapped syringe.
Vecchietti procedure (1965)
 involves the creation of a neovagina via dilatation with a traction device.
 An acrylic bead(olive) attached to sutures is placed on the perineum. Sutures are
passed intraabdominally and out above the pubic hair line under laparoscopic control,
and attached to a traction device which sits on the abdomen.
 Dilation over 5-7 days –about 1 cm/day
 Requires use of dilators.
Davydov Technique (1969)
 Utilizes peritoneum to line the newly dissected vesicorectal space. May be performed
laparoscopically.
 Peritoneum shown to undergo squamous metaplasia
Baldwin Intestinal Transposition and Variants (Colovaginoplasty)
 Sneguireff (1897) – rectum
 Baldwin (1904) – ileum.
o Problem: excessive mucous discharge, bleeding, and pain during intercourse
 Schimid (1956) – rectosigmoid.
o Ideal in anatomy and physiology,
o Loop of rectosigmoid is isolated, closed at one end, and brought down on its
vascular pedicle as a neovagina and then anastomosed to the perineum.
o Blood supply: superior hemorrhoidal artery from the inferior mesenteric artery.
Innervation of the flap from the autonomic system, with sympathetic (inferior
mesenteric and hypogastric nerve) and parasympathetic components
(hypogastric plexus).
-
Invasive - complications such as peritonitis, intestinal obstruction, and abdominal
scarring can occur.
-
periumbilical pain during intercourse
prolonged mucous discharge, malodour
less contracture than with the McIndoe procedure.
good tactility, adequate size, rare cavity constriction, and natural internal
lubrication.
 Laparoscopic sigmoid vaginoplasty has been described.
Williams Vulvo-Vaginoplasty
 Williams vaginoplasty uses a vulval flap to make a vaginal tube.
 The outer edges of the labia majora (if they are large enough) are stitched together
forming an outward, rather than an inward, extension to the vagina.
 advantage is that this method is a rapid, simple operation that does not damage the
urethra or rectum.
 Physiologically abnormal angle (less so in more modern variants - Creatsas) - like a
misdirected kangaroo's pouch rather than a true vagina.
 O'Brien's vulvovaginoplasty (PRS 1990)
o takes all the nonhairbearing skin within the labia majora in the shape of a ‘U’
shaped flap based anteriorly and creates a new vagina.
o This flap divides all the neurovascular input coming from the internal pudendal
system.
o requires dilation to increase the length and diameter of the neovagina, and
dilation must be carried out twice daily for an extended length of time
o modified by Okada (PRS 1996) with the use of tissue expanders
Labio Minora Flaps
 medium sized vaginal tube,
 needs to be dilated over a period of 2–3 months for depth
Local/Regional Flaps
 Muscle flaps ideal if there is significant dead space (ie post tumor ablation)
 Fascial flaps often difficult to fit into the natural shape of the perineum or get enough
width and depth of the vaginal cavity. Also skin-associated problems.
Omental Flaps (Bostwick 1979)
 Used in reconstructions for the irradiated urogenital region in association with
myocutaneous flaps or SSG
omental cylinder flap enwrapping the skin graft-covered stent is placed into the pelvis
Gracilis Myocutaneous Flap (1976)
 Unreliable skin territory.
1) Upper third receives only a few transversely oriented fasciocutaneous or
musculocutaneous perforators from the main gracilis muscular perforating
arteries.
2) The middle third of the skin overlying the gracilis muscle is supplied almost
exclusively by direct fasciocutaneous perforators from the superficial femoral
artery. In particular, there is a large fasciocutaneous perforator from the
superficial femoral artery that goes directly to the skin in the intermuscular
septum posterior to the sartorius and just anterior to the gracilis muscle. This
perforator forms the basis of the medial thigh fasciocutaneous flap as described by
Baek
3) Distal third by smaller fasciocutaneous perforators from the superficial femoral
artery and the descending genicular artery that give rise to the saphenous artery.
This latter artery forms the basis of the saphenous artery flap
 Use in VR first described by McCraw 1976 – bilateral gracilis flap (27% partial
necrosis rate)
 In an effort to reduce this, Whetzel et al 1997 described the myofasciocutaneous flap:
o Dotted line demonstrates dissection plane. Skin incisions are beveled to include
maximal deep investing fascia of medial thigh muscles. Dissection plane is onto
the sartorius muscle fibers and down into the septum between the sartorius and
adductor longus, ligating superficial femoral artery perforators close to their
origins. Posterior fascia of the gracilis is entirely preserved without direct
visualization of gracilis muscle fibers
o Tips:
1. Orientate axis of skin paddle more anteriorly (closer to sartorius) and
incorporate LSV
2. Account for skin dependency overlying gracilis
3. Width >6cm
4. If tunnel is not required, preserve proximal skin bridge
Inferior epigastric pedicled TRAM flap (Tobin 1988)
Transverse Skin Island(Rietjens 2002)
Technique
triangular skin island is drawn in the abdominal region with its base on the midline,
centered over the umbilicus, and running laterally for about 17 to 22 cm.
The base is about 8 cm in length, 4 cm above the umbilicus and 4 cm beside the
umbilicus. The triangle is drawn slightly oblique toward the upper part of the abdominal
wall to increase the length of the flap.
The skin-island triangle is incised, and the lateral tip of the flap is dissected just above the
anterior sheath of the transversus abdominis muscle forward the midline until the lateral
perforators arise from the rectus muscle. The anterior rectus sheath is incised only in the
periumbilical area up to the perforators. The anterior sheath is harvested with the flap in
the superior one-half of the muscle, whereas it is saved in the lower part. The skin island
is wrapped or coiled around a 50-cc syringe to obtain a tube reproducing the shape of the
vagina, and the fully mobilized flap can be transposed easily to the pelvis. The inferior
edge of the tubing skin flap is sutured inferiorly to repair the perineal defect and the new
introitus. The superior edge of the flap is fixed to the pelvic promontory to avoid a
perineal extrusion.
Vertical Skin Island
Transversus and Rectus Abdominis Musculoperitoneal (TRAMP) Composite Flap
Described by Hockel 1996
Composed of the entire rectus
abdominis muscle in continuity with an
ipsilateral epigastric part of the
transversus abdominis muscle, the
posterior rectus and transversalis fascia,
and the underlying parietal peritoneum.
Blood supply is provided by the deep
inferior epigastric artery.
Following transposition to the pelvis,
the epigastric musculoperitoneal tissue
plate is tubularized, leaving either an
anterior or a posterior slit, into which a
remaining strip of original vaginal
mucosa is sutured. The cranial end of
the musculoperitoneal tube is closed.
The caudal part of the flap is fixed to
the introitus of the vulva or to the
perineum
(A) Posterior aspect of the anterior abdominal wall showing the donor site of the TRAMP
flap on the left side. (B) The epigastric part of the elevated TRAMP flap is tubularized
except for a slit. The proximal end of that tube is closed. (C) The tubularized TRAMP
flap is transposed to the pelvis. The slit may be located either posteriorly or anteriorly (as
shown) to accept a strip of original vaginal mucosa that is preserved following anterior or
posterior exenteration.
Advantages:
1) The flap can be harvested through a midline abdominal incision, with no additional
scars.
2) Preservation of the anterior rectus sheath and the oblique muscles seems to prevent
postoperative hernia without requiring nonabsorbable mesh.
3) The technique is relatively simple to perform and has a low rate of morbidity.
4) The peritoneum presents a structure similar to the vaginal mucosa.
NB: The anterolateral abdominal wall is composed of the angiosomes of the following
source vessels: the deep circumflex iliac, the deep inferior epigastric, the deep superior
epigastric (internal thoracic), the lumbar, and the lower two to four posterior intercostal
vessels.
schematic drawing of the vascular supply (left side) and angiosomes (right side) of the
peritoneal aspect of the anterior body wall as seen from dorsally (solid line, TRAMP
flap;1, angiosome of the inferior epigastric artery; 2, angiosome of the internal thoracic
artery; 3, angiosomes of the lower intercostal arteries).
Fasciocutaneous Flaps
Medial thigh flap
2 descriptions:
1. Wang 1987
 Suprafascial plexus over gracilis
 3-4 nonaxial perforators from
i. ext pudendal artery
ii. musculocutaneus perforators from gracilis (MCFA)
iii. adductor magnus (MCFA)
2. Baek 1983
 Based on septocutaneous branch that arises from the SFA at apex of femoral
triangle
Anteromedial thigh flap
Hayashi 1988
 Based on a innominate (medial) descending branch of the LCFA between rectus
femoris and vastus medialis at lateral border of sartorius.
Superomedial thigh flap
Hirshowitz 1982
 Based on superficial branch of the deep external pudendal artery
 Transverse skin design at proximal thigh
Anterolateral thigh flap
Luo 2000
 Musculocutaneous (80 percent) / septocutaneous (20 percent) flaps
 The musculocutaneous type can be elevated as a perforator flap.
 long pedicle (8 to 12 cm)
 Can be raised with or without vastus lateralis muscle
 Direct closure if flap width does not exceed 7 cm.
 Sensate if harvested with lateral cutaneous nerve of thigh
Pudendal thigh flap
Wee 1989 – Singapore flap
Lehoczky 1987 – smaller dimensions
 sensate fasciocutaneous flap
 based on the terminal branches of the superficial perineal artery, (continuation of the
internal pudendal artery)
 innervated by the posterior labial branch of the pudendal nerve and perineal branches
of posterior cutaneous nerve of thigh
 adductor fascia raised to the posterior incision line
 Advantages:
1) it is a simple technique that can be completed in 2 or 2.5 hours with little blood
loss;
2) the flaps are very robust and have a reliable blood supply
3) no stents or dilators are required
4) the angle of inclination of the vagina is physiological and natural
5) the donor sites can be closed primarily, thus leaving an inconspicuous linear scar
in the well-hidden groin crease
6) the vagina is sensate and retains the same innervation of the erogenous zones of
the perineum and upper thigh.
 Disadvantages (Gynecol Oncol. 1994)
1) may have hair growth
2) vulvar pain
3) chronic discharge
4) protrusion of flap
 These vulvovaginal symptoms found to discourage patients and their partners from
genital contact.
Extended groin flap (Moschella 1994)
 Non hair bearing skin, no stent required, no vulvar distortion.
Lotus petal flap(Yi and Niranjan 1996)
 based on perforators around the perineum just lateral to the midline between the
vagina and the anus
 flaps resemble the petals of a lotus flower and are classified as inner, intermediate or
lower petals according to their proximity to the introitus, raised with deep fascia
(a) Inner lotus petal flap; (b) intermediate lotus petal flap; (c) lower petal flap. The dotted
areas illustrate the sites of the perforators.
Infragluteal thigh flap
 Fasciocutaneous consisting of skin, subcutaneous fat - raised in the infragluteal fold
 relies on infragluteal subdermal branches of the internal pudendal artery
 Knoll (1997) – includes the membranous layer of the superficial perineal fascia
 Hashimoto (1999) – fascia not required
Malaga flap (Giraldo PRS 1996)
 Similar to the neurovascular Singapore island flap but consist of a more proximal
dissection
Sexual Reassignment Surgery: Male-Female
History
 Transsexual - individuals who desire to live permanently in the gender role of the
opposite sex and who want to undergo sex-reassignment surgery. Now replaced by the
term gender identity disorder.
 Gender dysphoria syndrome, introduced by Fisk to define the distress resulting from
conflicting gender identity and sex of assignment.
 Transvestites, in contrast, are less gender dysphoric, or experience this distress only
periodically. They have a preference for cross-dressing but have no desire to change
their biological sex.
 Homosexuality is not considered an identity or a sexual disorder. It refers to an
individual's sexual preference for members of the same sex
Epidemiology
 M>F 3:1
 average prevalence of 1 in 12,000 biological men
Pathogenesis
 Theories
1. psychological and sociological,
2. biological
i. perinatal hormonal abnormalities ie congenital adrenal hyperplasia,
resistance to androgens
ii. alteration of gonadotrophin secretion
iii. sexual morphological differentiation of the brain
a. volume of the central subdivision of the bed nucleus of the stria
terminalis, a brain area that is essential for sexual behavior, found to be
larger in men than in women.
b. female-sized central subdivision of the bed nucleus of the stria
terminalis was found in male-to-female transsexuals
c. size of the central subdivision of the bed nucleus of the stria terminalis
was not influenced by sex hormones in adulthood and was independent
of sexual orientation
Management
1. Diagnosis based on precise and commonly accepted criteria as set out in the
Diagnostic and Statistical Manual of Mental Disorders, 4th Edition.
 goals of the diagnostic phase, which can last from 6 to 12 months, are as
follows: to define the exact form and tenacity of gender dysphoria, including an
assessment of its severity and the degree of transsexual conviction; to detect
those individuals who fulfill the requirements of a transsexual diagnosis and
who, as a last resort, would benefit from sex reassignment surgery; and to give
information concerning treatment, including both the possibilities and the
limitations of surgery
 patients who are found to have other psychiatric abnormalities, such as
psychotic syndromes, addiction problems, perversions, or biological
perturbations (i.e., intersexual states and endocrine disorders), are excluded
from the protocol and managed in an appropriate alternative manner.
2. Real-life test (also called real-life experience)
 confronts the subject with the everyday reality that he or she will meet once the
sex-reassignment process has been completely successful. During the real-life
test, the subject takes on the role of the desired sex in everyday activities, both
social and professional.
 Many patients may need to learn a more feminine demeanor. This period may
last between 12 and 18 months, and supportive psychotherapy is often necessary
in this period.
 Once the diagnosis of gender identity disorder is ascertained, an endocrinologist
confirms the absence of absolute contraindications to hormonal therapy; reviews
risks, side effects, and complications; and then follows the patients while on a
course of medical treatment.
 Most begin hormonal therapy during the real-life test.
 A reversible chemical castration is obtained first with the use of medications
that suppress one's own sex hormones (suppressive phase).
 One year later, patients start using hormones of the opposite sex (substitution
phase). The results of hormonal therapy vary among patients, but generally it
brings about changes to secondary sex characteristics, including a more
gynecoid pattern of fat distribution and variable breast development.
 Surgery is deferred until at least 1 year after starting hormonal treatment and at
least 2 years after the first psychological consultation.
Surgery
 Goals
1. to create a perineogenital complex as feminine in appearance and function as
possible
2. free of poorly healed areas, scars, and neuromas.
 Aims:
1. urethra should be shortened in such a way that the direction of the urinary stream
is downward in the sitting position and it should be free of stenosis or fistulas.
2. The neovagina should, ideally, be lined with moist, elastic, and hairless
epithelium. Its depth should be at least 10 cm and its diameter 30 mm.
3. The sensation should be sufficient to provide satisfactory erogenous stimulus
during sexual intercourse.
 Principles
1. Orchidectomy
2.
3.
4.
5.
6.
amputation of the penis
creation of the neovaginal cavity
lining of this cavity
reconstruction of a urethral meatus
construction of the labia and clitoris
Vaginoplasty
 Methods
1. application of nongenital skin grafts (Abraham 1931)
o similar to Abbe-McIndoe Inlay graft technique
o advantages of nongenital skin grafts are that they are a simple one-stage surgical
procedure, they create a sufficiently deep and wide vagina, they are non-hairbearing, and they carry a low risk of complications
o disadvantages include the residual scar in the donor area, the presence of a
circular scar at the introitus of the vagina (when no introital flaps are used),23
the tendency of the skin graft to shrink (postoperatively, daily dilation is
required), suboptimal sensation, and, as is true with all skin-lined neovaginas,
the absence of any natural lubrication
2. penile skin grafts (Fogh-Andersen 1956)
o advantages: it uses hairless skin; it is a one-stage procedure; donor scars are
inconspicuous; there is no traction on the abdominal pedicle and, thus, the
penile skin will remain where applied without causing a skin fold that can
obstruct the dorsal part of the neovaginal introitus and full-thickness skin grafts
undergo less contraction postoperatively compared with split-thickness skin
grafts
o disadvantages: better used as a flap, limited skin, dilators required
3. penile-scrotal skin flaps
o introduced by Gillies and Millard (1957)
o modifications:
i. inverted penile skin may be used solely on an abdominal pedicle as an
inside-out skin tube; this penile skin flap may be augmented with a small
triangular scrotal skin flap to break the circular introitus
ii. pedicled penile skin tube may be split open to form a rectangular flap that is
augmented by a rectangular, posteriorly pedicled scrotal skin flap
comparable in size
iii. inverted penile skin tube may be applied based on an inferior pedicle
o Advantages: less tendency to contract; inadvertent damage to the rectum may be
more easily corrected because it is immediately covered with vascularized
tissue; local innervation is provided; and the flap is virtually hairless.
o Disadvantages: a limited amount of penile skin may be available and that this
technique usually results in a widening of the anterior commissure, which can
leave the clitoris more exposed
o Although flaps have much less tendency to contract than grafts, these patients
are still required to use a dilator postoperatively during the first 6 months.
o Combining an abdominally pedicled penile skin flap with a posteriorly based
scrotal skin flap will produce an ideal anatomically located introitus and
favorable dimensions of the neovagina
o However, this technique will introduce hair-bearing scrotal skin and leads to a
transverse appearance of the vaginal introitus if a wide flap is used and it
provides little or no inherent lubrication
4. nongenital skin flaps
o flaps include medial thigh flap and inguinopudendal flaps
o advantages of using nongenital flaps include less risk of contraction and a
reduced period of postoperative dilation.
o drawbacks are donor-site morbidity and scarring, technical complexity (in some
cases the flaps are unreliable), and the fact that they tend to be bulky compared
with genital skin flaps.
o This added bulk may decrease the functional dimensions of the neovagina,
which can be particularly disadvantageous in male-to-female transsexuals
because the male pubic arch is less wide than its female counterpart
o flaps have no natural lubrication
5. pedicled intestinal transplants
o rectosigmoid colocolpopoiesis most common
o advantages
i. its length and a texture and appearance similar to a natural vagina
ii. only method that provides a vaginal lining with natural lubrication
o disadvantages:
i. production of mucus, however, may lead to excessive discharge
ii. lead to stasis and dehydration of mucus in the deepest portion of the vagina
iii. need for additional abdominal surgery
iv. colonic mucosa is more vulnerable and thus more accessible to sexually
transmitted diseases including human immunodeficiency virus infection
Clitorolabioplasty (Vulvoplasty)
 increasing focus on the aesthetic result of the labial complex (vulvoplasty) and on the
clitoris, which should provide adequate erogenous sensation.
Labia majora
 dependent on the use of either a penile flap or graft and the amount of the scrotal skin
remaining after resection
Commisuroplasty
 common secondary correction is the re-creation of the anterior commissure covering
the neoclitoris, which is often excessively exposed when a pedicled penile skin flap is
used
 usually performed with simple excision of intervening tissue or with a double
opposing Z-plasty.
Labia minora
 base of the penile skin to form the labia minora, which are then sutured to the deepithelialized area of the neoclitoris; thus, the neoclitoris is hooded with labia minora
Clitoris
 Brown (1976) used a reduced glans, which remained attached to its dorsal penile
neurovascular pedicle. However 33% clitoral necrosis rate
 Other options:
i. free composite graft of the tip of the penile glans to cover the shortened dorsal
neurovascular bundle;
ii. small bud of corpus cavernosum covered by penile skin
iii. corpus spongiosum as the vascular pedicle of the neoclitoris, preserving the
glans
 today most use the dorsal portion of the glans penis with the dorsal neurovascular
pedicle as described by Eldh
 Selvaggi et al. describe using the penile urethra to construct the region between the
urethral opening and the neoclitoris.
o urethra is incised longitudinally along its ventral aspect, folded open, and
sutured just inferior to the neoclitoris. In this way, a natural appearance is
produced, both in color and in texture.
o Construction of the labia minora and clitoral prepuce is accomplished with the
use of the thin inner layer of penile foreskin that is harvested in continuity with
the glans flap
Adjunctive procedures
1. facial feminizing surgery (e.g., chin reduction, malar augmentation, rhinoplasty,
supraorbital bar reduction)
2. body contouring (liposuction and fat redistribution)
3. breast augmentation

normal feminine breast volume is rarely obtained by hormonal therapy alone, and
as such, breast augmentation is required in the majority of the patients, even after
years of hormonal therapy.
 Breast augmentation, when requested by the patients, is usually performed at the
time of the vaginoplasty procedure
4. chondrolaryngoplasty (reduction of a prominent thyroid cartilage, or Adam's apple)
and voice change surgery (pitch-raising surgery).
 reserved for those patients who have had little success with voice therapy and
coaching
 usually follows the other gender reassignment procedures because intubation
should be avoided for 6 months after the voice operation
Modern Vaginovulvoplasty
Surgical Method – Penoscrotal flap
sketch of the perineum showing the line of primary incision.
The right spermatic cord is clamped and ligated.
(Left) primary incision is continued up the ventral side of the shaft of the penis. (Right)
Anterior flap is developed from the skin of the penis.
urethra is dissected from the shaft of the penis.
corpora cavernosa are separated to assure a minimal stump.
perineal dissection.
perineal dissection has been completed and the anterior flap perforated to position the
urethral meatus.
skin flaps are sutured and placed in position in the vaginal cavity.
preservation of the vaginal cavity is assured by use of a suitable vaginal form.