We treated 2 different types of intersexual patients who underwent a vaginoplasty with the pudendal-thigh flap. One was a female with testicular feminization syndrome for whom we reconstructed the total vagina with a pudendal-thigh flap, and the other was a female with an adrenogenital syndrome for whom we enlarged the introitus of the vagina with the same approach. There were no complications
such as a flap necrosis. In addition, there was no stricture of the neo-vagina and no urinary problem.</p

Hasegawa, Kenjiro

Kimata, Yoshihiro

Nakatsuka, Mikiya

Namba, Yuzaburo

Sugiyama, Narushi

Yamashita, Shuji

Okayama University Scientific Achievement Repository

Acta Medica OkayamaVolume 62, Issue 6 2008 Article 9DECEMBER 2008Vaginoplasty with a Pudendal-Thigh Flap inIntersexualsYuzaburo Namba∗ Narushi Sugiyama† Shuji Yamashita‡Kenjiro Hasegawa∗∗ Yoshihiro Kimata†† Mikiya Nakatsuka‡‡∗Department of Plastic and Reconstructive Surgery, Okayama University Graduate School ofMedicine, Dentistry and Pharmaceutical Sciences, y-namba@cc.okayama-u.ac.jp†Department of Plastic and Reconstructive Surgery, Okayama University Graduate School ofMedicine, Dentistry and Pharmaceutical Sciences,‡<y-namba@cc.okayama-u.ac.jp> Department of Plastic and Reconstructive Surgery,Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences,∗∗Department of Plastic and Reconstructive Surgery, Okayama University Graduate School ofMedicine, Dentistry and Pharmaceutical Sciences,††Department of Plastic and Reconstructive Surgery, Okayama University Graduate School ofMedicine, Dentistry and Pharmaceutical Sciences,‡‡Department of Gynecology and Obstetrics, Okayama University Graduate School ofMedicine, Dentistry and Pharmaceutical Sciences,Copyright c©1999 OKAYAMA UNIVERSITY MEDICAL SCHOOL. All rights reserved.Vaginoplasty with a Pudendal-Thigh Flap inIntersexuals∗Yuzaburo Namba, Narushi Sugiyama, Shuji Yamashita, Kenjiro Hasegawa,Yoshihiro Kimata, and Mikiya NakatsukaAbstractWe treated 2 different types of intersexual patients who underwent a vaginoplasty with thepudendal-thigh flap. One was a female with testicular feminization syndrome for whom we recon-structed the total vagina with a pudendal-thigh flap, and the other was a female with an adrenogen-ital syndrome for whom we enlarged the introitus of the vagina with the same approach. Therewere no complications such as a flap necrosis. In addition, there was no stricture of the neo-vaginaand no urinary problem.KEYWORDS: vaginoplasty, intersexual, pudendal-thigh flap∗Copyright c©2008 OKAYAMA UNIVERSITY MEDICAL SCHOOL. All rights reservedVaginoplasty with a Pudendal-Thigh Flap in IntersexualsYuzaburo Nambaa＊,  Narushi Sugiyamaa,  Shuji Yamashitaa,  Kenjiro Hasegawaa,   Yoshihiro Kimataa,  and Mikiya NakatsukabDepartments of aPlastic and Reconstructive Surgery and bGynecology and Obstetrics,  Okayama University Graduate School of Medicine,   Dentistry and Pharmaceutical Sciences,  Okayama 700ﾝ8558,  JapanWe treated 2 diﬀerent types of intersexual patients who underwent a vaginoplasty with the pudendal-thigh ﬂap.  One was a female with testicular feminization syndrome for whom we reconstructed the total vagina with a pudendal-thigh ﬂap,  and the other was a female with an adrenogenital syndrome for whom we enlarged the introitus of the vagina with the same approach.  There were no complica-tions such as a ﬂap necrosis.  In addition,  there was no stricture of the neo-vagina and no urinary problem.Key words: vaginoplasty,  intersexual,  pudendal-thigh ﬂapo date,  many procedures have been reported for vaginoplasties in intersexual patients,  such as the McIndoe procedure [1],  the perineal ﬂap [2] and the buttock ﬂap [3].  However,  all of these proce-dures have disadvantages.  We have performed vagino-plasties in many male-to-female transsexual patients with the modiﬁed pudendal-thigh ﬂap and have found it to be a valuable ﬂap free from complications [4].  The advantages of the pudendal-thigh ﬂap are that it can be elevated safely while retaining good vascularity,  it provides for the construction of a suﬃciently deep vagina without a skin graft and the donor scar is not so remarkable.  Herein we report 2 diﬀerent types of intersexual patients who underwent vaginoplasty with the pudendal-thigh ﬂap.Case Report　 Case 1, 29- old woman with a testicular feminization syndrome. This patient consulted our department for a vaginal reconstruction.  She had already started female hormonal therapy and revealed normal breasts,  hardly any axillary or pubic hair growth,  adhesion of the bilateral labia,  no introitus of the vagina and no palpable uterus or adnexa.  At an additional examination,  the uterus and adnexa proved to be absent,  the serum testosterone concentration was substantially increased and the karyotype was 46,  XY.  The patient had undergone a bilateral inguinal hernia operation and the testicles were extirpated in childhood.　 M-shaped bilateral pudendal-thigh ﬂaps were designed and were elevated above the medial thigh fascia including the posterior pudendal vessels and nerves to ensure the survival of the ﬂap and its sensi-tivity (Figs.  1,  2).  The cavity for the vagina was created in the space between the prostate and rectum.  For this part of the surgery,  ﬁnger dissection is considered to be the easiest and most reliable method. We introduced one index ﬁnger into the rectum and dissected with the other index ﬁnger.  We constantly conﬁrmed the thickness between the cavity and rectum with both index ﬁngers to ensure lack of injury to the rectum (Fig.  3).  The depth of the cavity was almost TActa Med.  Okayama,  2008Vol.  62,  No.  6,  pp.  415ﾝ419CopyrightⒸ 2008 by Okayama University Medical School.Case Report http ://escholarship.lib.okayama-u.ac.jp/amo/Received July 7, 2008 ; accepted August 14, 2008. ＊Corresponding author. Phone : ＋81ﾝ86ﾝ235ﾝ7212; Fax : ＋81ﾝ86ﾝ235ﾝ7210E-mail : y-namba@cc.okayama-u.ac.jp (Y. Namba)1Namba et al.: Vaginoplasty with a Pudendal-Thigh Flap in IntersexualsProduced by The Berkeley Electronic Press, 200810cm (Fig.  4).  The edges of the bilateral pudendal-thigh ﬂaps were sutured together to form a pouch lining the vaginal cavity (Fig.  5).  The top of the pouch was ﬁxed at the bottom of the cavity with 2 anchor sutures.  The adhesive labia were cut about 3cm in the midline and the labial ﬂaps of both sides were ﬁxed at the bases of the M-shaped ﬂap (Fig.  6).  There appeared to be no need to retain any implement,  such as a prosthesis,  in the vagina and we this usually inserted only isodine-soaked gauze into the cavity.  The urethral catheter and the drains were removed within 5 days of the operation.  Sexual activity was permitted and vaginal dilation with a dilator was started within 3 months of the operation.  There was no stricture of the neo-vagina and no urinary problem 1 year after the operation (Fig.  7).416 Acta Med.  Okayama　Vol. 62, No. 6   Namba et al.Fig. 1　 Design of the pudendal-thigh ﬂap and the incision line for the labial ﬂap.Fig. 2　 Elevation of the pudendal-thigh ﬂap.Fig. 3　 Cavity formation with ﬁnger dissection.Fig. 4　 Completed cavity for the vagina. Fig. 5　 Pouch formation to line the vagina cavity.2Acta Medica Okayama, Vol. 62 [2008], Iss. 6, Art. 9http://escholarship.lib.okayama-u.ac.jp/amo/vol62/iss6/9　 Case 2, 19- old woman with an adrenogeni-tal syndrome. This patient had previously under-gone a vaginoplasty,  and a cavity had been made without lining its raw surface,  which was connected with the cecal congenital vagina.  This primary opera-tion resulted in an annular stricture of the constructed vagina.  We therefore planned to enlarge the stricture site and transfer the ﬂaps to the defect.  The surgical technique was modiﬁed via the perineal approach since this patient had normal anorectal anatomy.　 The bilateral pudendal-thigh ﬂaps were designed (Fig.  8) and the stricture site was incised (Fig.  9).  The ﬂaps were then elevated above the medial thigh fascia and the original urinary meatus completely exposed (Fig.  10).  The pudendal-thigh ﬂaps were transferred into the defect of the posterior vaginal wall (Fig.  11).  The ventral wall of the mobilized urogenital sinus was opened and used to create a mucous lined vestibule through the perineal approach,  following which the labial ﬂaps were pulled down and were ﬁxed at the bases of the pudendal-thigh ﬂaps (Fig.  12).  The inserted ﬂaps provided suﬃcient width of the vaginal introitus and canal (Fig.  13).  The postoperative course was uneventful and vaginal dila-tion with a dilator was started within 3 months of the operation.  There was no recurrence of vaginal stric-ture one year after the operation (Fig.  14).417Vaginoplasty with a Pudendal-Thigh FlapDecember 2008Fig. 6　 Immediately after the operation.Fig. 7　 One year after the operation.Fig. 8　 Design of the pudendal-thigh ﬂap,  A catheter tube is inserted into the urogenital sinus.Fig. 9　 Incision of the vagina introitus and the stricture site.3Namba et al.: Vaginoplasty with a Pudendal-Thigh Flap in IntersexualsProduced by The Berkeley Electronic Press, 2008Discussion　 Testicular feminization is a syndrome caused by androgen insensitivity which occurs in a complete and an incomplete form.  Inguinal hernia is a common clinical presentation for a young child with this dis-ease.  Most patients usually undergo excision of their hypertrophic clitoris when young and almost all of them have been brought up as a female.  They present at hospitals for amenorrhea and often desire a vagino-plasty.　 The adrenogenital syndrome is a disorder of adre-nal steroid synthesis and can occur in both males and 418 Acta Med.  Okayama　Vol. 62, No. 6   Namba et al.Fig. 10　 Elevation of the pudendal-thigh ﬂap, Another catheter tube is inserted into the original urethral meatus.Fig. 11　 Flap transfer into the defect of the posterior vaginal wall.Fig. 12　 Immediately after the operation.Fig. 13　 Easy insertion of the SS-sized Cuscoʼs speculum.Fig. 14　 One year after the operation.4Acta Medica Okayama, Vol. 62 [2008], Iss. 6, Art. 9http://escholarship.lib.okayama-u.ac.jp/amo/vol62/iss6/9females.  In female cases with this syndrome,  a uro-genital sinus exists and there is usually no introitus of the vagina,  so they present at a hospital for hematuria and amenorrhea.　 Vaginal enlargement plasty with a skin graft in these cases is always problematic,  since shrinking,  particularly of the vaginal introitus,  occurs.  However,  a suﬃciently large ﬂap such as the pudendal-thigh ﬂap inserted into the “defect” of the posterior vaginal wall provides suﬃcient width to the vaginal introitus and canal.  The ventral wall of the mobilized urogenital sinus is further opened and used to create a mucous lined vestibule through the perineal approach.　 The pudendal thigh ﬂap for the vaginoplasty was ﬁrst reported by V. T. Joseph from Singapore,  so it is sometimes called the “Singapore ﬂap”.  It is usually used for reconstruction of the vagina,  scrotum and urethra.  This ﬂap is well-recognized as containing the posterior pudendal vessels and can be elevated safely [5ﾝ9].  It also contains the posterior pudendal nerves and can be used it as a sensory ﬂap; furthermore,  it can be made hairless using several laser depilation treatments before the operation.  Ideally,  a recon-structed vagina should be fully lined with a hairless ﬂap without a skin graft.　 The most diﬃcult challenge of vaginoplasty in tes-ticular feminization syndrome case is how to recon-struct the labia major to achieve a good shape.  In vaginoplasties in male-to-female transsexual cases,  abundant skin and soft tissue from the scrotal area can be obtained and used to reconstruct the labia major.  If the penis is also present,  so we can use it to resurface the vestibule with the penile ﬂap.  In the case of tes-ticular feminization syndrome,  however,  there is usually no scrotum and no penis,  so it is hard to get a good volume of tissue for the labial reconstruction and vestibular resurfacing.  If the patient wants to get a better contoured labia major,  we have to add optional procedures such as a skin graft to the vestibule,  a dermal-fat graft or an adiposal ﬂap transfer to the labia major.  Neither of our current cases requested an additional procedure.　 In the case of female adrenogenital syndrome,  a cecal vagina and an urogenital sinus already exist,  so the full depth of the vagina does not have to be cre-ated.  For these cases we make only the introitus and short canal of the vagina.  In a lower urogenital sinus type like this case,  we can use the urogenital sinus to create a mucous lined vestibule.  In addition the labial ﬂaps can be used only to reconstruct the labia major,  so a good contour of the labia major can be achieved.　 Conclusion. We reconstructed the vagina with a pudendal-thigh ﬂap for 2 diﬀerent types of inter-sexual patients.  There was no complication such as ﬂap necrosis,  the donor scar was not remarkable and the patients were satisﬁed with the results.  We believe that the pudendal-thigh ﬂap is the one of the best sources for vaginoplasty in intersexual patients.References 1. Buss JG and Lee RA: McIndoe procedure for vaginal agenesis:results and complications.  Mayo Clin Proc (1989) 64: 758ﾝ761. 2. Hagerty RC,  Vaughn TR and Lutz MH: The perineal artery axial ﬂap in reconstruction of the vagina.  Plast Reconstr Surg (1988) 82: 344ﾝ345. 3. Dumanian GA and Donahoe PK: Bilateral rotated buttock ﬂaps for vaginal atresia in severely masculinized females with adrenogenital syndrome.  Plast Reconstr Surg (1992) 90: 487ﾝ491. 4. Namba Y,  Sugiyama N,  Yamashita S,  Hasegawa K,  Kimata Y,  Ishii K and Nasu Y: Vaginoplasty with an M-Shaped Perineo- Scrotal Flap in a Male-to-Female Transsexual.  Acta Med Okayama (2007) 61: 355ﾝ360. 5. Wee JT and Joseph VT: A new technique of vaginal reconstruc-tion using neurovascular pudendal thigh ﬂaps: A preliminary report.  Plast Reconstr Surg (1989) 83: 701ﾝ709. 6. Woods JE,  Alter G,  Meland B and Podratz K: Experience with vaginal reconstruction utilizing the modiﬁed Singapore ﬂap.  Plast Reconstr Surg (1992) 90: 270ﾝ274. 7. Joseph VT: Pudendal- thigh ﬂap vaginoplasty in the reconstruction of genital anomalies.  J Pediatr Surg (1997) 32: 62ﾝ65. 8. Giraldo F,  Mora MJ,  Solano A,  González C and Fernández VS:Male perineogenital anatomy and clinical application in genital reconstructions and male-to female sex reassignment surgery.  Plast Reconstr Surg (2002) 109: 1301ﾝ1310. 9. Selvaggi G,  Monstrey S,  Depypere H,  Blondeel P,  Landuyt KV,  Hamdi M and Dhont M: Creation of neovagina with use of a pudendal thigh fasciocutaneous ﬂap and restoration of uterovaginal continuity.  Fertil Steril (2003) 80: 607ﾝ611.419Vaginoplasty with a Pudendal-Thigh FlapDecember 20085Namba et al.: Vaginoplasty with a Pudendal-Thigh Flap in IntersexualsProduced by The Berkeley Electronic Press, 20086Acta Medica Okayama, Vol. 62 [2008], Iss. 6, Art. 9http://escholarship.lib.okayama-u.ac.jp/amo/vol62/iss6/9

Vaginoplasty with a Pudendal-Thigh Flap in Intersexuals

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