Aesth Plast Surg DOI 10.1007/s00266-016-0620-2
I N N OV A T I V E T E C H N I QU E S
GENERAL RECONSTRUCTION
Sensate Vagina Pedicled-Spot for Male-to-Female Transsexuals: The Experience in the First 50 Patients Robert C. J. Kanhai1
Received: 22 October 2015 / Accepted: 21 January 2016 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2016
Abstract Background The cosmetic and functional results of vaginoplasty by inversion of penile and scrotal skin in male-to-female transsexuals are, in general, satisfactory. The sexual arousal function of the neo-female genitalia depends mainly on the clitoris. Due to the lack of a sexual arousal organ within the neo-vagina, patients are denied sexual arousal during penetration of the neo-vagina. This necessitated improvement of sexual innervation within the neo-vagina. Methods A new technique to create a sexual arousal organ in the anterior wall of the neo-vagina by creation of a sensate pedicled-spot, in combination with the neoclitoroplasty. Results In this paper, this new technique and part of the long-term results in the first 50 patients with a sensate pedicled-spot plasty are presented and discussed. Conclusions Sensate pedicled-spot plasty has proven to be a safe innovative technique which lead to adequate sexual functionality in all patients. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords Male-to-female transsexual Sensate vagina G-spot Sexual arousal organ Vaginoplasty
& Robert C. J. Kanhai
[email protected] 1
Department of Plastic and Reconstructive Surgery, Medisch Centrum Alkmaar, Wilhelminalaan 12, 1815 JD Alkmaar, The Netherlands
Introduction The cosmetic and functional results of vaginoplasty by inversion of penile and scrotal skin in male-to-female transsexuals are, in general, satisfactory. One of the goals of sex reassignment surgery is to create tactile and erogenous sensitivity in the reconstructed genitals. A neo-clitoroplasty [1, 2] performed during primary gender-confirming surgery for male-to-female transsexuals, is a procedure which has been considered state of the art for over 40 years, gives sexual functionality to the neo-female genitalia. This goal falls short due to the inner neo-vagina’s lack of erogenous sensitivity, having instead only tactile sensitivity of the skin and prostate. This shortcoming persists despite the refinements to the vaginoplasty throughout the years [3]. To improve the sexual functionality, I have innovated a technique that creates a sexual sensate vagina pedicled-spot in the male-to-female transsexuals, which could be compared with the G-spot, in combination with neoclitoroplasty. Existence of the G-Spot is controversial despite ancient Indian texts in sexology (Kamas´astra) from the 11th century onwards providing proof that their authors were aware of this area. This area was subsequently, in Europe, to be termed the Gra¨fenberg zone, a sexually arousable zone found in the front area of the vagina. Since the 1980s, this so-called Gra¨fenberg zone, popularly termed ‘‘G-spot’’, has been controversially discussed both medically as well as in popular science, firstly in the United States and subsequently in Europe [4]. Because there are no ultrasonographic images or anatomical pictures of the G-Spot, and the female prostate has no anatomical structure [5] that can cause an orgasm, some claim that the G-Spot does not exist and the
123
Aesth Plast Surg
hypothetical area named G-spot should not be defined with Grafenberg’s name [6]. In this paper, the new technique to create a sensate-spot in the neo-vagina and part of the long-term results in the first 50 patients treated in this way to enhance the sexual functionality of the neo-vagina are presented and discussed.
Patients From August 2009 to May 2014, neo-clitoroplasty in combination with a sensate vagina pedicled-spot-plasty has been performed during primary penile skin inversion vaginoplasty in 50 male-to-female transsexuals. This procedure, which extends operating time on average by 15 min, involves applying a part of the dorsal aspect of the corona glandis, pedicled on the dorsal penile neurovascular bundles, into the neo-vagina. The indications for gender-confirming surgery were agreed upon by the gender dysphoria team at the VuMC. All the patients were operated on in the Medisch Centrum Alkmaar, by one surgeon. At the time of the operation, the average age of these patients was 38.4 years (range 19–65 years). Follow-up in all the patients ranged from 17 to 73 months (mean 46.7 months) and is currently ongoing.
Surgical Technique For the vaginoplasty, I employ a modification of the abdominally pedicled penile skin inversion technique enhanced by a dorsal rectangular scrotal skin flap [7, 8]. For this, the penile skin tube with the fascia penis superficialis (dartos fascia) and superficial dorsal cutaneous veins adherent to it are dissected from the erectile corpora, leaving the dorsal neurovascular bundles unharmed and covered by Buck’s deep penile fascia [9]. Subsequently, two longitudinal incisions through Buck’s fascia, but not through the tunica albuginea, are made bilateral to the dorsal neurovascular bundles (Fig. 1). By blunt and sharp dissection, the intermediate fascia, including both dorsal neurovascular bundles, is raised from the tunica albuginea all the way from the base of the glans to the urogenital diaphragm (Fig. 2). After undermining part of the glans, two small parts of its corona and a part of the preputium is left attached to this pedicle which will be divided. One part will serve as a vascularized sensate neoclitoris with its preputial hood [1, 2, 10] and the other part will be the sensate pedicled-spot (Fig. 2). The sensate pedicled-spot will be attached to the anterior wall of the vagina in the ostium region (Fig. 3) and invisible in frontal view (Fig. 4).
123
Fig. 1 After dissection of the penile skin tube of the erectile corpora, two longitudinal incisions through Buck’s fascia, but not through the tunica albuginea, are made bilateral to the dorsal neurovascular bundles. (1 clitoris part, 2 sensate pedicled part)
Results and Discussion Twenty patients noticed erogenous feeling in both the clitoris and the sensate pedicled-spot, during the same period of time. This was, on average, 9.2 weeks (range 5–48 weeks). Two patients had their first sexual feeling in the sensate pedicled-spot prior to sensation in the clitoris. The delay in the feeling in the sensate pedicled-spot, versus the clitoris, was on average 11.5 weeks (range 1–32 weeks) in 20 patients postoperatively. Hypersensibility occurred in two patients of the sensate pedicled-spot along with hypersensibility of the clitoris. In six patients, the timing of sensibility in the sensate pedicled-spot was uncertain. In four of these six patients also the timing of the function of the clitoris was uncertain. The erogenous sensibility in the clitoris recurrence period ranged from 5 days to 48 weeks (average 7.6 weeks) postoperatively in 46 patients. The erogenous sensibility in the sensate pedicled-spot recurred on average 12.6 weeks (range 5 days to 48 weeks) in 44 patients post-operatively. After 2 weeks, 12 patients had sexual sensibility in the clitoris and 6 patients in the sensate pedicled-spot. Fifty percent of the patients had sexual sensibility after 5 weeks in the clitoris and after 10 weeks in the sensate pedicledspot. After 15 weeks, 82 % of the patients had sexual sensibility in the clitoris and 62 % of the patients in the sensate pedicled-spot. By one patient, the sensate pedicled-spot was lost due to pressure but remarkably the sensate potency was not lost in
Aesth Plast Surg Fig. 2 After undermining part of the glans, two small parts of its corona and a part of the preputium is left attached to this pedicle which will be divided. One part will serve as a vascularized sensate neo-clitoris with its preputial hood [1, 2, 9] and the other part will be the sensate vagina pedicled-spot (1 clitoris part, 2 sensate pedicled part)
Fig. 3 The sensate pedicled-spot at the anterior wall of the neo-vagina in the ostium region (2 sensate pedicled part)
Fig. 4 Result of a vaginoplasty after 1 year. The sensate pedicledspot at the anterior wall of the neo-vagina is invisible in frontal view
this case. Erogenous sensibility was found to recur in all of the patients. In this series, three patients had a per-operative rectal lesion, all of which were directly closed. No incidence of
rectal-vaginal fistulas occurred. Furthermore, one patient developed a post-operative bleed which was treated conservatively. Seventeen patients underwent one or more aesthetic corrections regarding the introitus, labia majora, or clitoral region. Infection occurred in two patients who subsequently received antibiotics. Post-operative bladder retention occurred in 10 %, all of which resolved spontaneously after 1 week. Nine patients underwent meatoplasty due to diminished urine flow and one patient due to a pinpoint meatus [3, 11]. There is a modest learning curve for this innovative procedure and this technique will lead to superior sexual functional results. Because the male-to-female transsexuals are not familiar with having female sexual organs and orgasms, pre-operative education should be given to increase the knowledge of how to use and what to expect post-operatively of their sexual functions and organs.
123
Aesth Plast Surg
This innovative procedure creates a more sexual arousal neo-vagina in the male-to-female transsexual. Because creating a sensate vagina pedicled-spot in combination with a neo-clitoroplasty can only be done in the primary sex reassignment surgery, I think this could be considered the new state-of-art standard for male-to-female transsexuals. Compliance with Ethical Standards Conflict of interest interest to disclose.
The author declares that he has no conflict of
References 1. Brown J (1976) Creation of a functional clitoris and aesthetically pleasing introitus in sex conversion. In: Hueston JJ, Marchac D (eds) Transactions of the sixth international congress of plastic and reconstructive surgery. Masson, Paris, pp 654–655 2. Hage JJ, Karim RB (1996) Sensate pedicled neoclitoroplasty for male transsexuals: Amsterdam experience in the first 60 patients. Ann Plast Surg 36(6):621–642 3. Wangjiraniran B, Selvaggi G, Chokrungvaranont P, Jindarak S, Khobunsongserm S, Tiewtrnon P (2015) Male-to-female vaginoplasty: Preecha’s surgical technique. J Plast Surg Hand Surg 49(3):153–159
123
4. Syed R (1999) Knowledge of the ‘‘Gra¨fenberg zone’’ and female ejaculation in ancient Indian sexual science: a medical history contribution. Sudhoffs Arch 83(2):171–190 5. Puppo V (2011) Anatomy of the Clitoris: revision and clarifications about the anatomical terms for the Clitoris proposed (without scientific bases) by Helen O’Connell, Emmanuele Jannini, and Odile Buisson. ISRN Obstet Gynecol 2011:261464 6. Pastor Z (2010) G spot-myths and reality. Ceska Gynekol 75(3):211–217 7. Bouman FG (1988) Sex reassigment surgery in male to female transsexuals. Ann Plast Surg 21:526–531 8. Karim RB, Hage JJ, Bouman FG et al (1995) Refinements of pre-, intra-, and postoperative care to prevent complications of vaginoplasty in male transsexuals. Ann Plast Surg 35:279–284 9. Tobin CE, Benjamin JA (1944) Anatomical study and clinical consideration of the fasciae urinary extravasation from the penile urethra. Surg Gynecol Obstet 79:195–204 10. Eldh J (1993) Construction of a neovagina with preservation of the glans penis as a clitoris in male transsexuals. Plast Reconstr Surg 91:895–900 11. Krege S, Bex A, Lu¨mmen G, Ru¨bben H (2001) Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients. BJU Int 88(4):396–402
