The aesthetic items scale: A tool for the evaluation of aesthetic outcome after breast reconstruction

__Background:__ Valid tools to assess aesthetic outcomes after breast reconstructive surgery are scarce. Previously a professional aesthetic assessment scale was introduced, the Aesthetic Items Scale (AIS). We aim to determine if this method is a valid and reliable tool to assess aesthetic outcome after breast reconstructive surgery. __Methods:__ The study population was consenting women who underwent prophylactic mastectomy with subsequent implant-based breast reconstruction. The aesthetic outcome with regard to breast volume, shape, symmetry, scars, and nipple areola complex was rated on a 5-point scale using standardized photographs to give a summed total score. Photographs were evaluated by the patient, 5 plastic surgeons, and 3 mammography nurses. An overall rating of aesthetic outcome on a 1-10 scale was given separately. We determined the intraclass correlation coefficient and assessed interobserver agreement. To assess validity, we calculated the correlation between total score and overall rating of aesthetic outcome. __Results:__ Interobserver reliability was highest between plastic surgeons for the subitem and overall scores and ranged between 0.56 and 0.82. The summed score of the AIS correlates strongly with the overall rating in professionals but not in patients. __Conclusions:__ The AIS is a valid and reliable method for evaluating aesthetic outcome of breast reconstruction by plastic surgeons. The results indicate that patients judge aesthetic outcome differently, taking into account factors that are not represented in the AIS. Professionals can use this method to evaluate surgical results, but other measurements are needed to map satisfaction of the patient with her breasts

The Penile Inversion Vaginoplasty. From the Functional to the Desired

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Subcutaneous Mastectomy in Female-to-Male Transsexuals: A Retrospective Cohort-Analysis of 202 Patients

Introduction. Subcutaneous mastectomy is the first surgical procedure to be completed by female to male transsexuals after appropriate mental health and endocrine therapy. Objectives of subcutaneous mastectomy in this group are to masculinize the chest by the removal of breast tissue and skin excess, reduction and proper positioning of the nipple-areola complex, obliteration of the infra-mammary fold, and ideally with a minimal of chest wall scars. In this study, the largest series of subcutaneous mastectomies in female-to-male transsexuals to date is presented. Aims. Our aim was to determine relations between surgical technique, risk factors, complications, reoperations and secondary corrections in female-to-male transsexuals. Methods. We performed a retrospective survey study on 404 mastectomies in 202 female-to-male transsexuals during the period of 2000-2011. Main Outcome Measures. Primary outcomes for this study were complication rate, acute reoperations, secondary corrections, surgical time, and length of hospital stay in relation to the surgical technique used. Results. The average age of these patients at time of the intervention was 31years (±10) with an average BMI of 25kg/

Total laparoscopic sigmoid vaginoplasty

OBJECTIVE: To demonstrate step by step our technique for total laparoscopic sigmoid vaginoplasty. DESIGN: Surgical video tutorial. SETTING: Academic medical center. PATIENT(S): Transgender women with penile hypoplasia or with a failed primary vaginoplasty and biological women with either acquired or congenital absence of a functional vagina. INTERVENTION(S): An original technique for total laparoscopic sigmoid vaginoplasty is shown on video. Surgery is performed via a simultaneous abdomino-perineal approach. The genital surgeon dissects the neovaginal cavity and performs a bilateral orchiectomy and shortening of the urethra. Out of penile and scrotal skin, a clitoro-vulvaplasty is created. Meanwhile, the laparoscopic surgeon mobilizes the sigmoid segment and transects it down to the base of the sigmoid arteries. The segment is guided in an iso-peristaltic way through the neovaginal tunnel on to the perineum. The distal staple line is opened and sutured in an exaggerated interdigitating fashion to the perineum and inverted penile skin. Length of the segment is measured with a transilluminated perspex dildo, after which the segment is stapled at the proper level. A neovaginopexy is performed on the promontory. Bowel continuity is restored with an intra-abdominal side-to-side oversewn stapled anastomosis. The patient provided written informed consent for the use of this video in this article. MAIN OUTCOME MEASURE(S): None. RESULT(S): Given current literature, intestinal vaginoplasty is associated with low complication rates. Since 2008 our group performed 42 primary and 21 secondary procedures, mainly in transgender women, with at least 1 year of clinical follow-up. Complications comprised three rectal perforations and two anastomotic leakages. These were addressed laparoscopically without long-term fistula formation. There were no conversions to laparotomy. CONCLUSION(S): Total laparoscopic sigmoid vaginoplasty is a feasible and safe procedure in the hands of an experienced team with the right infrastructure. It provides good surgical and functional results. In selected cases it is indicated for primary vaginoplasty, as well as for revision vaginoplasty

Aesthetic and Functional Outcomes of Neovaginoplasty Using Penile Skin in Male-to-Female Transsexuals

Introduction: In the treatment of transgender women, the surgical construction of a neo-vagina, or vaginoplasty, is the final stage in the transition to the desired gender. Surgeons aim to create a neovagina that is in function and appearance as close to a biological vagina as possible. However, to date, it is insufficiently clear whether transgender women are satisfied with the functional and cosmetic outcomes of vaginoplasty. Aims: Our aim was to assess if penile skin inversion neovaginoplasty performed in transgender women meet the objectives strived for, by determining functional and aesthetic outcomes, as well as the physical and sexual well-being and satisfaction. Methods: We performed a retrospective survey study on 49 transgender women who underwent vaginoplasty using the penile skin inversion technique. Participants were asked to fill out the Female Sexual Function Index (FSFI), a combination of the Amsterdam Hyperactive Pelvic Floor Scale-Women (AHPFS-W) and the Female Genital Self-Imaging Scale, and a short questionnaire for self-evaluation of vaginoplasty. Photographs of the genitalia were taken for objective assessment by an independent panel. Main Outcome Measures: Primary outcomes were the functional and aesthetic evaluation as perceived by the trangender women themselves. Secondary outcomes were the aesthetic evaluation of the vaginoplasty by an independent panel. Results: Functionality and appearance were both given an average score of 8 out of 10. Despite this high score, 56% is sexually dysfunctional according to the FSFI, mainly because of not being sexually active, or due to problems with lubrication and discomfort. In 75%, the result met the expectation and 70% thinks their genital is feminine enough. Conclusion: This study demonstrates that, despite relatively low FSFI scores, this group of transgender women is very satisfied with both the functional and aesthetic results of neovaginoplasty using penile skin inversion. Buncamper ME, Honselaar JS, Bouman M-B, Özer M, Kreukels BPC, and Mullender MG. Aesthetic and functional outcomes of neovaginoplasty using penile skin in male-to-female transsexuals

Outcome of Vaginoplasty in Male-to-Female Transgenders: A Systematic Review of Surgical Techniques

Introduction: Gender reassignment surgery is the keystone of the treatment of transgender patients. For male-to-female transgenders, this involves the creation of a neovagina. Many surgical methods for vaginoplasty have been opted. The penile skin inversion technique is the method of choice for most gender surgeons. However, the optimal surgical technique for vaginoplasty in transgender women has not yet been identified, as outcomes of the different techniques have never been compared. Aim: With this systematic review, we aim to give a detailed overview of the published outcomes of all currently available techniques for vaginoplasty in male-to-female transgenders. Methods: A PubMed and EMBASE search for relevant publications (1995-present), which provided data on the outcome of techniques for vaginoplasty in male-to-female transgender patients. Main Outcome Measures: Main outcome measures are complications, neovaginal depth and width, sexual function, patient satisfaction, and improvement in quality of life (QoL). Results: Twenty-six studies satisfied the inclusion criteria. The majority of these studies were retrospective case series of low to intermediate quality. Outcome of the penile skin inversion technique was reported in 1,461 patients, bowel vaginoplasty in 102 patients. Neovaginal stenosis was the most frequent complication in both techniques. Sexual function and patient satisfaction were overall acceptable, but many different outcome measures were used. QoL was only reported in one study. Comparison between techniques was difficult due to the lack of standardization. Conclusions: The penile skin inversion technique is the most researched surgical procedure. Outcome of bowel vaginoplasty has been reported less frequently but does not seem to be inferior. The available literature is heterogeneous in patient groups, surgical procedure, outcome measurement tools, and follow-up. Standardized protocols and prospective study designs are mandatory for correct interpretation and comparability of data

Intestinal Vaginoplasty Revisited: A Review of Surgical Techniques, Complications, and Sexual Function

Introduction: Vaginal (re)construction is essential for the psychological well-being of biological women with a dysfunctional vagina and male-to-female transgender women. However, the preferred method for vagina (re)construction with respect to functional as well as aesthetic outcomes is debated. Regarding intestinal vaginoplasty, despite the asserted advantages, the need for intestinal surgery and subsequent risk of diversion colitis are often-mentioned concerns. The outcomes of vaginal reconstructive surgery need to be appraised in order to improve understanding of pros and cons. Aims: To review literature on surgical techniques and clinical outcomes of intestinal vaginoplasty. Methods: Electronic databases and reference lists of published articles were searched for primary studies on intestinal vaginoplasty. Studies were included if these included at least five patients and had a minimal follow-up period of 1 year. No constraints were imposed with regard to patient age, indication for vaginoplasty, or applied surgical technique. Outcome measures were extracted and analyzed. Main Outcome Measures: Main outcome measures were surgical procedure, clinical outcomes, and outcomes concerning sexual health and quality of life. Results: Twenty-one studies on intestinal vaginoplasty were included (including 894 patients in total). All studies had a retrospective design and were of low quality. Prevalence and severity of procedure-related complications were low. The main postoperative complication was introital stenosis, necessitating surgical correction in 4.1% of sigmoid-derived and 1.2% of ileum-derived vaginoplasties. Neither diversion colitis nor cancer was reported. Sexual satisfaction rate was high, but standardized questionnaires were rarely used. Quality of life was not reported. Conclusion: Based on evidence presently available, it seems that intestinal vaginoplasty is associated with low complication rates. To substantiate these findings and to obtain information about functional outcomes and quality of life, prospective studies using standardized measures and questionnaires are warranted. © 2014 International Society for Sexual Medicine

Clinical Characteristics and Management of Neovaginal Fistulas After Vaginoplasty in Transgender Women

OBJECTIVE: To describe our experience and results obtained in the management of neovaginal fistulas after vaginoplasty as gender reassignment surgery in transgender women. METHODS: A retrospective study was performed of 1,082 transgender women who underwent 1,037 primary and 80 revision vaginoplasty procedures between 1990 and 2015. Thirty-five women underwent both primary and later revision vaginoplasty at our institution. Patient, clinical, surgical, and outcome characteristics were reviewed. RESULTS: We treated 25 (2.3%) patients for 13 rectoneovaginal, 11 urethroneovaginal, and one pouch-neovaginal fistulas. Patients undergoing revision vaginoplasty were at higher risk of rectoneovaginal fistula development (0.8% compared with 6.3%, P<.01, odds ratio 8.6, 95% confidence interval 2.7-26.9). Of 23 intraoperatively identified and oversewn rectal perforations, four (17.4%) patients developed a rectoneovaginal fistula. In four patients, fecal diversion was achieved through temporary colostomy or ileostomy with direct (n=1) or delayed (n=3) fistula closure. In six patients, urethroneovaginal fistula arose after a complication such as meatal stenosis. Two patients underwent temporary suprapubic cystostomy for urinary diversion. In most patients, fistulectomy and primary closure or a local advancement flap was sufficient to treat the fistula. CONCLUSION: Neovaginal fistulas are uncommon after vaginoplasty. Symptoms of neovaginal fistulas are comparable with those of vaginal fistulas. In most patients, the diagnosis can be made based on symptoms and physical examination alone. It seems that a complicated course (eg, intraoperative rectal perforation or meatal stenosis) predisposes for fistula formation. Surgical repair of neovaginal fistulas is associated with few intraoperative and postoperative complications and does not seem to impair neovaginal function