Phalloplasty with an Innervated Island Pedicled Anterolateral Thigh Flap in a Female-to-Male Transsexual

Since 2001, we have been performing phalloplasty with a radial forearm free flap as the flap of first choice in female-to-male transsexuals (FTMTS). In the present case, a 22-year-old FTMTS with a negative Allen test, we achieved good results by performing phalloplasty with an innervated island pedicled anterolateral thigh flap using the "tube within a tube" technique, in which the penis and urethra are constructed with a single flap. While phalloplasty with an island-pedicled or free anterolateral thigh flap has been reported previously, the present case seems to be the first of phalloplasty with an innervated island-pedicled anterolateral thigh flap using the "tube within a tube" technique. As compared to a forearm flap, use of an innervated island-pedicled flap may have the following advantages in phalloplasty:1) no need for a microsurgical technique;2) no scars at noticeable sites;3) small functional loss in the flap donor area;4) no sacrifice of major blood vessels. Thus, this technique seems to be a useful clinical alternative for phallic reconstruction

Total phallic reconstruction after penile amputation for donkey bite: Case report and review of the literature

There are very few reported cases of traumatic amputation of the male genitalia due to animal bite. The management involves thorough washout of the wounds, debridement, antibiotic prophylaxis, tetanus and rabies immunization followed by immediate reconstruction or primary wound closure with delayed reconstruction, when immediate reconstruction is not feasible. When immediate reconstruction is not feasible, long-term good functional and cosmetic results are still possible in the majority of cases by performing total phallic reconstruction. In particular, it is now possible to fashion a cosmetically acceptable sensate phallus with incorporated neourethra, to allow the patient to void while standing and to ejaculate, and with enough bulk to allow the insertion of a penile prosthesis to guarantee the rigidity necessary to engage in penetrative sexual intercourse

An improved method of supercharged transposed latissimus dorsi flap with the skin paddle for the management of a complicated lumbosacral defect

OBJECTIVE: Treatment of nonhealing wounds of lower back often poses a powerful challenge. We present one of the first report of treatment of a lumbosacral defect with a supercharged latissimus dorsi flap with the skin paddle. CASE REPORT: We report a case of a 59 yearold man with myeloma of the sacral spine who underwent radiotherapy and chemotherapy and subsequently, laminectomies and placement of hardware for ongoing paresis and spine instability. Then, he developed an open wound and osteomyelitis of the spine with culture positive tuberculous granulomas. After multiple surgical debridement, he presented to our service and was treated with a single stage debridement followed by the performance of a latissimus dorsi musculocutaneous flap based on paraspinal perforators and supercharged. RESULTS: This solution, allowed for augmentation of blood flow to the muscle with the inferior gluteal artery, provided coverage of the defect resistant to the pressure, and simplified post-operative management of the patient. CONCLUSIONS: Alternative treatment options, including free tissue transfer, posed difficulties in finding suitable recipient vessels near the defect, in inserting the flap so as to restore its original length without compromising blood flow, and in postoperative care of the patient. Treatment of a lumbosacral defect with a supercharged latissimus dorsi flap with the skin paddle may represent a milestone procedure for complicated lower spine wounds

The effects of androgen therapy on the endometrium of transgender men

Individuals who identify themselves as transgender have gender identities that do not match their anatomical sex. Females who identify as male, also known as female-to-male transgender (FTM), may opt to undergo hormonal and surgical treatment in order to transition to the male phenotype, including high-dose testosterone treatment to develop male secondary sexual characteristics and surgical procedures. Currently, the recommendation is for the patient to have a hysterectomy within five years of initiating testosterone therapy to decrease the risk of developing endometrial cancer. However, long-term testosterone treatment has not been proven to cause an increased risk of endometrial cancer. With the use of gene expression and immunohistochemical studies, this study aimed to show no upregulation of genes associated with proliferation (Ki-67) and endometrial cancer (ZIC2) in endometrial tissue from FTM individuals treated with long-term testosterone compared to endometrial tissue from postmenopausal women, premenopausal women with benign endometrium, and women with endometrial cancer. Our findings showed that Ki-67 and ZIC2 expression in the FTM samples was significantly lower than in the endometrial cancer samples. Our findings call into question the concept that long-term testosterone treatment causes neoplastic changes in endometrial tissue and the need for routine hysterectomy in these patients.2018-07-11T00:00:00

Sex assignment in conditions affecting sex development

The newborn infant with atypical genitalia presents a challenging clinical scenario and requires expert input. There have been appreciable advances in our knowledge of the underlying causes that may lead to a mere difference or a more serious disorder of sex development (DSD), the natural history of conditions, as well as the short and long-term complications of these conditions themselves, together with the clinical interventions that are associated with these conditions. With this information, the DSD expert can be more confident when discussing options with the parents of the newborn infant. By working within a multidisciplinary team, the expert should be able to support the family whilst individualising the management plan so that it is also cognizant of the shifts in societal attitudes and expectations around concepts of diversity and openness. It is, therefore, likely that the practice of assigning sex, especially in those cases where sex assignment is unclear on expert assessment, will continue to show temporal, social and geographical variations. It is imperative that clinical data for rare conditions such as these are collected in a standardized format and shared through a common registry so that any evidence that is used for future shifts in practice has a stronger foundation than that which is currently available

Postoperative soft tissue defects in the ankle area : The etiology and methods of reconstruction

The risk is obvious for soft tissue complications after operative treatment of the Achilles tendon, calcaneal bone or after ankle arthroplasty. Such complications after malleolar fractures are, however, seldom seen. The reason behind these complications is that the soft tissue in this region is tight and does not allow much tension to the wound area after surgery. Furthermore the area of operation may be damaged by swelling after the injury, or can be affected by peripheral vascular disease. While complications in this area are unavoidable, they can be diminished. This study attempts to highlight the possible predisposing factors leading to complications in these operations and on the other hand, to determine the solutions to solve soft tissue problems in this region. The study consists of five papers. The first article is a reprint on the soft tissue reconstruction of 25 patients after their complicated Achilles tendon surgeries were analysed. The second study reviews a series of 126 patients after having undergone an operative treatment of calcaneal bone fractures and analyses the complications and possible reasons behind them. The third part analyses a series of corrections of 35 soft tissue complications after calcaneal fracture operations. The fourth part reviews a series of 7 patients who had undergone complicated ankle arthroplasties. The last article presents a series of post operative lateral defects of the ankle treated with a less frequently used distally based peroneus brevis muscle flap and analyses the results. What can be conducted from these studies is that in general, the results after the correction of even severe soft tissue complications in the ankle region are good. For the small defects around the Achilles tendon, the local flaps are useful, but the larger defects are best treated with a free flap. We found that a long delay from trauma to surgery and a long operating time were predisposing factors that lead to soft tissue complications after operatively treated calcaneal bone fractures. The more severe the injury, the greater the risk for wound complication. Surprisingly, the long-term results after infected calcaneal osteosyntheses were acceptable and the calcaneal bone seems to tolerate chronic infections very well if the soft tissue is reconstructed successfully. Behind the complicated ankle arthroplasties, unexpectedly high number of cases experiencing arteriosclerosis of the lower extremity was found. These complications lead to ankle fusion but can be solved with a free flap if the vascularity is intact or can be reconstructed. For this reason a vascular examination of the lower extremity arteries of the patients going to ankle arthroplasty is strongly recommended. Moreover postoperative lateral malleolar wound infections which typically create lateral ankle defects can successfully be treated with a peroneus brevis muscle flap covered with a free skin graft.Tutkimuksen tarkoituksena oli selvittää mahdollisia leikkauksen jälkeisille haavan paranemisongelmille altistavia tekijöitä ja arvioida eri kudossiirteiden sopivuutta pehmytkudosten jälleenrakentamiselle nilkan alueella. Leikkauksen jälkeisiä pehmytkudosongelmia nilkan alueella on mahdotonta välttää, mutta niiden esiintyvyyttä voidaan vähentää. Vamman, sekä leikkauksen aiheuttama kudosturvotus yhdistettynä nilkan alueen niukkaan pehmytkudokseen altistavat komplikaatioille. Tämän tutkimuksen perusteella voidaan todeta, että pääsääntöisesti vakavienkin pehmytkudospuutosten korjaaminen nilkan alueella onnistui hyvin. Akillesjänteen alueella paikalliset ihokielekkeet toimiva hyvin pienissä kudospuutoksissa, mutta suuremmat kudospuutokset täytyy paikata vapaalla mikrovaskulaarisella kielekkeellä. Myös pitkä odottaminen vamman syntymästä itse leikkaukseen ja pitkä leikkausaika altistivat potilaat haavatulehduksille. Pehmytkudoksen uudelleen rakentamisen onnistumisen myötä olivat lopuliset tulokset hyviä kantaluun alueella, sillä kantaluu näytti sietävän hyvin infektioita. Nilkan ulkosyrjän pehmytkudoksen jälleenrakentamisessa peroneus brevis lihaskieleke toimii hyvin vapaalla ihonsiirteellä peitettynä. Potilailla, joilla esiintyi nilkan proteesileikkauksen jälkeisiä haavatulehduksia oli yllättävän suurella osalla alaraajan verisuonten kalkkeutumaa. Suosittelemmekin siksi, että kyseistä leikkausta edeltävästi potilaiden alaraajojen valtimoverenkierto tutkittaisin

A team approach to the indication for gender reassignment surgery in transsexuals resulting in long-term outcome improvement

At the University of Basel (Switzerland), a multidisciplinary team was established for pre-operative selection and treatment of patients with gender dysphoria. As a result, the indications for surgical gender reassignment could be judged with considerably greater accuracy than previously possible. In the 9-year period of this prospective study only 14 of 57 patients with gender dysphoria were selected for surgical treatment. At the time of this survey, six patients are still under psychiatric preoperative evaluation, and six further male-to-female transsexuals are under hormonal treatment awaiting surgery. Following the operation, only one of nine male-to-female patients is socially unstable and that patient's quality of life is worse than prior to gender reassignment. Of the female-to-male transsexuals, all four are stable in their professional and family relations. In conclusion, a comprehensive evaluation of patients with gender dysphoria and the conclusive indications established within the team considerably improved the postoperative outcome of gender reassignmen