Transsexualism or sex dysphoria is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,1 and in the International Classification of Diseases, Tenth Revision2 (F64.X). In many countries, the prevalence of sex dysphoria is rapidly increasing, although numbers have not been reliably established. In the literature, prevalence has been calculated at 1 in 5,000 to 1 in 12,000 or more.3–5 In Sweden, the diagnosis F64.0 was given to 1,127 patients in 2013, which is twice the number only 3 years earlier and 3 times the number 3 years before that (unpublished data, personal correspondence with the National Board of Health and Welfare, Stockholm, September 30, 2015). Public healthcare systems do not support the cost of sex reassignment surgery in all countries. However, in Sweden, all inhabitants are eligible to receive such surgery, including any corrections, at no cost to the patient. For the past 30 years, Karolinska University Hospital has been one of Sweden’s supraregional centers providing surgical care for transsexual patients. Several variations of the surgical technique for male to female sex reassignment have been described.6–9 Commonly, penile skin is used for lining a part of the neovaginal cavity together with scrotal flaps or skin grafts.6,10 Considerable debate exists regarding whether penile skin alone is sufficient to provide lining for the complete vaginal depth needed.
Disadvantages of using skin flaps and/or skin grafts include the creation of intravaginal scars, use of hair-bearing skin, and rougher skin quality compared with the pliable and soft penile skin. At Karolinska University Hospital, we use solely penile skin with a penile inversion technique for nearly all cases. During the past 15 years, only 4 patients received a skin flap in addition to penile skin (<1%). Here, we describe this surgical technique and outcome measurements of a large cohort of patients to investigate if penile skin alone is sufficient to create an adequate neovaginal depth.
PATIENTS AND METHODS
Eighty patients who had undergone male to female sex reassignment surgery (primary surgery) using penile skin for the neovaginal lining at Karolinska University Hospital between 2000 and 2014 were included.11 The patients were followed up prospectively and measured for neovaginal depth under general anesthesia during a secondary elective surgical procedure. The indications for a second procedure were planned secondary surgery (see below), breast surgery, or any minor refinement procedure. The time between the primary surgery and the measurements performed at secondary surgery was minimum 6 months to allow for complete healing. Data on patient age, height, weight, and circumcision were collected at baseline. Body mass index (BMI) was calculated. Information on postoperative complications was collected retrospectively. After primary surgery, the patients were prescribed a postoperative self-dilatation regimen. Self-reported compliance with this regimen was noted. The depth of the neovaginal cavity of the patients was measured in the lithotomy position at the end of the surgical procedure using a semirigid silicone vaginal dilator (30 × 180 mm). All measured neovaginal cavities accepted the dilator with regard to width, but no special attempt to measure the width specifically was made. The dilator was directed horizontally and allowed to bottom out in the neovaginal cavity, and a marker was used to draw a line parallel to the position of the inner labia (Fig. 1). The distance from the tip of the dilator to the drawn mark was recorded in the patient chart. Measurements were performed according to a written protocol and after a teaching session to assure a comparable measuring technique between surgeons. Measurements of neovaginal depth were compared with the literature on vaginal depth in biological women, including when aroused or nonaroused.12–14
Mean vaginal depth and range were calculated by age category, BMI category, circumcision, postoperative complication, and compliance with the dilatation regime. The Pearson correlation coefficient was used to evaluate the association between vaginal depth and the continuous covariates. Simple linear regression models and a multivariate regression model were used to estimate the effect of all the before-mentioned variables on the primary outcome (vaginal depth). Two-tail P values were calculated with a significance level of 0.05.
The study had institutional approval with a register permit from Stockholms Läns Landsting (2010-11-30 and 2015/2225-31).
The patient is placed in the lithotomy position under general anesthesia with epidural analgesia. A caudally based scrotal flap is marked and raised for surgical access to the perineal area. The bulbous musculature and the bulb of the urethra are dissected off the proximal corpus spongiosa and discarded. Orchidectomy is done by ligation of the funiculi bilaterally. Creation of a neovaginal vault in the area between the urethra and the rectum follows by sharp dissection through the perineal musculature and the perineal raphe. Once the contractile musculature has been incised, blunt dissection, under bimanual palpation, directed toward the prostate is performed until sufficient depth and width is reached (Fig. 2A). A penile prosthesis (40 mm diameter × 160 mm length) is inserted to ascertain a sufficient neovaginal space (Fig. 2B). The penile skin is next incised distally along the proximal glans border and separated from the corpora and the spongious tissue (Fig. 3A). This skin forms a cranial circumferential skin flap, a “pouch.” The prepuce fold is dissected, and this skin is used to increase the length of the pouch. The distal pouch opening corresponding to the foreskin area is closed by suturing after which the skin pouch is inverted (Fig. 3B). A triangular piece of the proximal dorsal glans penis is drawn out and dissected off the penis, superficial to the tunica albuginea to preserve innervation and vascular supply to the erogenous tissue. Thus, a sensate flap is raised for use as a neoclitoris (Fig. 4). The urethra is dissected completely off the corpora and divided at a suitable length (Fig. 4) before the penile remnants are amputated close to the symphysis at radix penis, and each corpora cavernosa is ligated. The skin of the penis is invaginated into the neovaginal cavity, the scrotal flap is discarded, and the posterior commissure is sutured. This invagination (Fig. 5) causes a significant cranial pull of the skin, which causes the posterior commissure to rise upward to cover a part of the vaginal orifice. The prepelvic skin is likewise stretched, and the anterior commissure is consequently widened (Fig. 5). We do not undermine the prepelvic skin or dissect the lower abdomen to preserve maximum vascularization to the penile skin. The penile skin is not anchored into the neovaginal space by suturing. This pull of the skin is the cause of the mandatory secondary procedure as described below. Next, semicircular and rhomboid incisions cranial to the neovagina are performed, and the neoclitoral flap and the urethra, respectively, are sutured into place. The lateral incisions are closed by suturing, and the neovaginal cavity is packed with vaseline gauze before bandaging. In case of bleeding or fecal contamination, the surgical area is inspected, but otherwise, the bandages are kept until the fourth postoperative day when the dressings are changed and the urethral catheter is removed. Mobilization is allowed at days 3 to 5.
Vaginal dilatation is started on the fourth postoperative day and continues for minimum 1 year. The dilatation regimen consists of initial dilatation with a 25-mm-wide semirigid silicon dilator for 20 minutes 2 to 3 times per day. After 3 weeks, the patient uses a rigid plastic dilator with a width of 35 mm.
Secondary surgery is performed no earlier than 6 months after the primary surgery to allow for complete healing and stretching of the tissues. A vulvoplasty is conducted with a vertical incision in the caudal vaginal orifice (posterior commissure) to deepen the commissure (Fig. 6). Inner labia may be created by repositioning of the commissure skin anteriorly or by creation of a skin fold using the extra skin available at the posterior commissure. Coverage of the neoclitoris and narrowing of the anterior commissure are achieved by using a skin flap enveloped from each side (Fig. 6). No procedures to stretch or widen the neovaginal space are performed at secondary surgery.
Eighty (n = 80) patients who had been operated on for sex reassignment surgery were measured for vaginal depth at the time of a secondary surgical procedure. At least 6 months had passed after the primary operation with a median time of 44 months. As we prescribe a strict dilatation scheme for the first year only, we examined statistically if measurements at 6 months were adequate to indicate a stable result. Patients measured between 6 months and 1 year compared with patients measured between 1 and 2 years (when dilatation frequency is up to the patient) showed no statistical difference in terms of depth (10.7 versus 10.5 cm; P = 0.808; confidence interval, –2.385351 to 1.863782). The average vaginal depth was 10.2 cm with a median value of 10.4 cm and a range between 1 and 16 cm (Table 1 and Fig. 7). Of the 80 participants, 11 (13.7%) experienced 1 or more postoperative complications, whereas 69 (86.3%) experienced none (Table 1). A majority of the participants adhered to the dilatation regime (68 participants; 85.0%), 11 (13.8%) did not, and 1 participant (1.2%) did not report this. The Pearson’s correlation coefficient did not indicate a statistically significant association between vaginal depth and BMI (Pearson correlation coefficient, 0.007; P = 0.95) or age (Pearson correlation coefficient, 0.089; P = 0.43).
A multiple regression model was used to estimate the effect of different covariates on vaginal depth. In a multivariate analysis, noncompliance with dilatation regime and having had any postoperative complication were found to be associated with the outcome (Table 2). Neither circumcision nor age did statistically affect vaginal depth. We found no association between vaginal depth and BMI, neither as a continuous variable nor as a categorical variable. Vaginal depth in biological women as published from magnetic resonance imaging scans was 6.3 cm (range, 4.1–9.5),14 the cast measured 6.9 to 14.8 cm,13 and the aroused versus nonaroused averages were 7 to 8 versus 11 to 12 cm.12 The depth measured after neovaginal reconstruction was thus within the range of normal for biological women for all published measurement modalities (Table 3).
Determining the optimal surgical procedure for a complex (re)construction, such as gender reassignment, cannot be done for all patients as a group. Vaginal depth is the most common area of discussion among patients and surgeons within this field. We compared our data on 80 patients with the literature on biological women and found that the long-term result after sex reassignment surgery using the above-described technique is well within the range of measures in biological women.13,14 Possibly, the width of the dilator could affect measurements, which is an inherent shortcoming of a study protocol as described here. We have, however, not experienced that the 30-mm wide dilator was difficult to use in any patient. Although we do not know what percentage of our patients do have heterosexual intercourse, our results indicate that it should indeed be anatomically possible. Buncamper et al15 have recently shown that transsexual women operated on using a similar neovaginoplasty technique using penile skin are generally satisfied in terms of functional and aesthetic outcome as determined by questionnaires (Female Sexual Function Index), which is in concordance with our experience.
Using solely penile skin for neovaginal construction is efficient in terms of procedural time consumption with a low rate of major complications.11 Penile skin is supple and non-hair bearing.15,16 Furthermore, no intravaginal scarring or donor-site morbidity is inflicted. The secondary surgery, necessitated by the pronounced stretching of the skin in the prepelvic area, is a minor 20-minute procedure performed as an outpatient case and has the advantage of also giving the surgeon a late “second look” with a chance to refine untoward scarring or dog-ears, and it may be combined with ancillary procedures, such as breast augmentation. Although small skin flaps, such as perineal flaps, could be used to widen the posterior fornix, we do not use these because the secondary surgery is scheduled anyway, and therefore, such corrections are handled then. The cosmetic outcome can thus be well controlled (Supplemental Figs. 1–4, http://links.lww.com/PRSGO/A224). In our study, patients who had extremely limited usable penile skin, that is, because of circumcision or of malformations or scarring, were not included as they would have received primary surgery using another technique. However, during the past 15 years, only 4 patients were operated on with another technique (2 were circumcised and had a short penis, 1 had a congenital micropenis, and 1 patient had a previous injury to the penis). Consequently, our experience is that nearly all patients will have sufficient skin if all skin is used for the vaginal lining and that occurrences with insufficient penile skin are very few. The surgeon’s discretion will have to guide whether circumcized patients have enough skin for this technique. Furthermore, it should be noted that penile measurements have not been performed and that other geographical populations may have less available skin. We prescribe a vaginal dilatation protocol for at least 1 year after surgery where the patient uses a dilator to prevent contracture of the vaginal vault (20 minutes 2–3 times daily). Patients who admitted to not having adhered to the prescribed postoperative dilatation regimen had, as expected, a significantly reduced average vaginal depth with almost 4 cm. Empirically, dilatation has limited effect in increasing depth but is necessary to prevent reduction of the vaginal space or, in worst case, even collapse and protrusion.18,19 In comparison to surgical techniques using scrotal flaps or skin grafts, our postoperative dilatation protocol is not significantly different.20 The use of pedicled intestinal tissue7,21 may limit the need for postoperative dilatation but impose possible long-term risks of colitis22 and a perceived increased morbidity by operating intraabdominally. Age at primary surgery was not correlated with vaginal depth, and the mean difference in centimeters between age groups was within 1.3 cm. Having had any complication was associated with lesser neovaginal depth. Nonetheless, because this group was small, the presence of 2 patients with a major complication (rectal injury and deep bleeding, respectively) and a resultant very shallow depth makes the overall effect of less serious complications difficult to interpret. In contrast, bodily habitus as approximated by BMI, which could be expected to lessen the vaginal depth because of intraabdominal downward pressure, did not affect the outcome negatively. This indicates that this technique is also suitable for heavier patients, and such parameters should not be the basis for diverting the surgeon toward other techniques.
Benefits of using solely penile skin for creating a neovagina in transsexual patients include reduced scarring, avoidance of intravaginal scar contracture, and vaginal lining without hair-bearing skin. In conclusion, these results support the use of solely penile skin for neovaginal construction to accomplish an anatomically adequate neovaginal depth in the vast majority of patients, provided that the postoperative dilatation protocol is adhered to.
3. Becking AG, Tuinzing DB, Hage JJ, et al. Transgender feminization of the facial skeleton. Clin Plast Surg. 2007;34:557564.
4. Tugnet N, Goddard JC, Vickery RM, et al. Current management of male-to-female gender identity disorder in the UK. Postgrad Med J. 2007;83:638642.
5. Olyslager F, Conway L. On the Calculation of the Prevalence of Transsexualism
, in WPATH 20th International Symposium, Chicago, Illinois
6. Selvaggi G, Ceulemans P, De Cuypere G, et al. Gender identity disorder: general overview and surgical treatment for vaginoplasty in male-to-female transsexuals. Plast Reconstr Surg. 2005;116:135e145e.
7. Karim RB, Hage JJ, Mulder JW. Neovaginoplasty in male transsexuals: review of surgical techniques and recommendations regarding eligibility. Ann Plast Surg. 1996;37:669675.
8. Small MP. Penile and scrotal inversion vaginoplasty for male to female transsexuals. Urology 1987;29:593597.
9. Wroblewski P, Gustafsson J, Selvaggi G. Sex reassignment surgery for transsexuals. Curr Opin Endocrinol Diabetes Obes. 2013;20:570574.
10. Horbach SE, Bouman MB, Smit JM, et al. Outcome of vaginoplasty in male-to-female transgenders: a systematic review of surgical techniques. J Sex Med. 2015;12:14991512.
11. Sigurjonsson H, Rinder J, Möllermark C, et al. Male to female gender reassignment surgery: surgical outcomes of consecutive patients during 14 years. JPRAS Open 2015;6:6973.
12. Masters MD, William H, Johnson VE. Human Sexual Response
. 1966.Toronto, New York: Bantam Books.
13. Pendergrass PB, Reeves CA, Belovicz MW, et al. The shape and dimensions of the human vagina as seen in three-dimensional vinyl polysiloxane casts. Gynecol Obstet Invest. 1996;42:178182.
14. Barnhart KT, Izquierdo A, Pretorius ES, et al. Baseline dimensions of the human vagina. Hum Reprod. 2006;21:16181622.
15. Buncamper ME, Honselaar JS, Bouman MB, et al. Aesthetic and functional outcomes of neovaginoplasty using penile skin in male-to-female transsexuals. J Sex Med. 2015;12:16261634.
16. Sohn M, Bosinski HA. Gender identity disorders: diagnostic and surgical aspects. J Sex Med. 2007;4:11931207quiz 1208.
17. Socialstyrelsen. Transsexuella och övriga personer med könsidentitetsstörningar - Rättsliga villkor för fastställelse av könstillhörighet samt vård och stöd. 2014.Stockholm, Sweden: Socialstyrelsen.
18. Kuhn A, Santi A, Birkhäuser M. Vaginal prolapse, pelvic floor function, and related symptoms 16 years after sex reassignment surgery in transsexuals. Fertil Steril. 2011;95:23792382.
19. Bucci S, Mazzon G, Liguori G, et al. Neovaginal prolapse in male-to-female transsexuals: an 18-year-long experience. Biomed Res Int. 2014;2014:240761.
20. Karim RB, Hage JJ, Bouman FG, et al. Refinements of pre-, intra-, and postoperative care to prevent complications of vaginoplasty in male transsexuals. Ann Plast Surg. 1995;35:279284.
21. Lemberger RJ, Bishop MC. Neovaginoplasty using rectosigmoid colon on a superior rectal artery pedicle. BJU Int. 2001;87:269272.
22. Webster T, Appelbaum H, Weinstein TA, et al. Simultaneous development of ulcerative colitis in the colon and sigmoid neovagina. J Pediatr Surg. 2013;48:669672.
Supplemental Digital Content
Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved.