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Application of Embryonic Equivalents in Male‑To‑Female Sex Reassignment Surgery Original Article

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Application of Embryonic Equivalents in Male‑To‑Female Sex Reassignment Surgery Original Article Published online: 2019-07-26 Original Article Application of embryonic equivalents in male‑to‑female sex reassignment surgery Balakrishnan Margabandu Thalaivirithan, Maithreyi Sethu, Dinesh Karuvakkurichi Ramachandran, Mahadevan Kandasamy, Jaganmohan Janardhanam Department of Plastic Reconstructive and Faciomaxillary Surgery, Madras Medical College, Chennai, Tamil Nadu, India Address for correspondence: Dr. Balakrishnan Margabandu Thalaivirithan, Old No. 15, New No. 10, Thiruvalluvar Street, Rangarajapuram, Kodambakkam, Chennai - 600 024, Tamil Nadu, India. E-mail: [email protected] ABSTRACT Introduction: The feeling of incongruence between phenotypic sex and psychological recognition of self‑gender is termed gender dysphoria. Transsexualism is the most extreme form of this disorder. Aims and Objectives: The aims and objectives of the study are to evaluate the esthetic and functional outcome of embryonic equivalents‑based male‑to‑female sex reassignment surgery in transwomen using the institutional scoring system. Materials and Methods: Thirty transwomen who had undergone male-to-female embryonic equivalents-based sex reassignment surgery (MFEEbSRS) from October 2012 to March 2016 were retrospectively studied. The outcome was evaluated by two independent plastic surgeons, based on interview with the individuals, visual assessment, and measurements. Surgical Technique: Clitoris was created from reduced glans on dorsal penile pedicle mounted on the crura of the conjoined corpora cavernosa. De‑gloved unfurled proximal penile skin formed the introitus, hood for clitoris and labia minora. Neo-external urethral meatus was fashioned from the distal portion of the bulbar urethra. Distal de-gloved inverted penile tube flap was used for the creation of neovagina. Reduced scrotal flaps formed the labia majora. Observation and Results: The maximum length of neovagina in the study was 12 cm, and the average length was 9.8 cm. Based on our institutional scoring system for the assessment of esthetic and functional outcome, we got excellent results in all transwomen. Conclusion: The esthetic and functional outcome in all the patients was good. All patients were relieved of their primordial feminine tension and satisfied with the surgery. Their personality, lifestyle, and self-esteem improved remarkably following surgery. KEY WORDS De-gloved penile inversion flap; male to female embryonic equivalents-based sex reassignment surgery; transgenders; transwomen; vaginoplasty This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, Access this article online as long as appropriate credit is given and the new creations are licensed under the identical terms. Quick Response Code: Website: For reprints contact: [email protected] www.ijps.org How to cite this article: Thalaivirithan BM, Sethu M, DOI: Ramachandran DK, Kandasamy M, Janardhanam J. Application of 10.4103/ijps.IJPS_62_18 embryonic equivalents in male‑to‑female sex reassignment surgery. Indian J Plast Surg 2018;51:155‑66. 155 © 2018 Indian Journal of Plastic Surgery | Published by Wolters Kluwer - Medknow Thalaivirithan, et al.: Sex reassaignment surgery, transformation to transwomen INTRODUCTION neurodevelopment, contribute to this. Many sexually dimorphic nuclei have been found in the hypothalamus.[8] ender Dysphoria (GD) is seen in some diversified One of these is the central subdivision of Bed nucleus individuals who have varying degrees of of Stria Terminalis.[9] In human males, the volume of this Gdisgruntlement of their anatomical, phenotypic nucleus and its number of neurons is twice compared to sex, and genderness. In addition, they have intense females. In transwomen, it was similar to female controls. desire to possess secondary sexual properties of the opposite sex. GD is a unique human condition that This article explores an anatomical approach of converting is classified behaviorally but treated medically by and harmonizing the external genitalia according to the hormones and surgery. In 2010, the World Professional mind of these transwomen. Association for Transgender Health (WPATH)[1] declared GD to be dissociated from functional and psychological Aims and objectives disorders. This has led to a vast change in the social and The aims and objectives of the study are to evaluate the political scenario for the GD worldwide. The treatment esthetic and functional outcome of male-to-female embryonic includes self-rehabilitation through a multidisciplinary equivalents-based sex reassignment surgery (MTFEEbSRS) team approach and the traditional triadic sequence; the using the institutional scoring system [Table 1]. final step of which being sex reassignment surgery in this complete human transformation.[2] MATERIALS AND METHODS In 1966, the influential book by Benjamin, The Transsexual Thirty transwomen who had undergone MFEEbSRS Phenomenon,[3] made many clinicians aware of the between October 2012 and March 2016 were potential benefits of sex reassignment surgery. In 1973, retrospectively studied [Table 1]. Preoperative counseling the diagnosis of “GD syndrome” was introduced by Fisk[4] and pertinent legal issues were explained, and to define the distress resulting from conflicting gender informed consent was obtained from each transwoman. identity and sex of assignment. “Transsexualismus,” the Institutional Ethical Committee permission was obtained term was coined by Magnus Hirschfeld in 1923. The term for this study. “transsexualism” first appeared officially in the widely used Diagnostic and Statistical Manual of Mental Tools used for the assessment of esthetic and Disorders Edition in 1980.[5] In the recent edition, the functional outcome term transsexualism was replaced by the term GD. Institutional scoring system for the evaluation of esthetic and functional outcome was used and each transwoman The feeling of incongruence between phenotypic sex and was assigned a score at the end of the follow-up period psychological recognition of self-gender is termed GD. by two independent plastic surgeons, and the average Transsexualism is the most extreme form of this disorder. was obtained [Table 1]. • Age of the patients ranged from 21 to 42 years (average Meerwijk and Sevelius in their meta-analysis study of 31.5 years) published in 2017 revealed in the USA that 390/100,000 • There were no comorbid conditions associated adults are estimated to be transgender.[6] No definite with the patients except that 15 individuals tested figures are available for India,[7] but transgender positive (for human immunodeficiency virus I and II), population is palpably on the rise. but their CD4 count was >400 cells/mm3. Androgen produced by the male fetus brings about changes Inclusion criteria in the fetal brain, which are essential for the development • 30 Transsexuals who fulfilled the Benjamin criteria[3] of male gender identity. Gender identity is reinforced by and had undergone male to female SRS were only the gender role the child is exposed to, in the early years. included in the study • Individuals who had completed the prescribed period Transsexuals, however, identify themselves with the of cross-living and hormonal therapy psychological sex, which is opposite to their physical • Individuals with stable mental status, assessed by sex, and hence feels trapped in the wrong body. Recent psychiatrists research indicates that genetic factors, as well as fetal • Those who wanted to have a serviceable vagina. Indian Journal of Plastic Surgery Volume 51 Issue 2 May‑August 2018 156 Thalaivirithan, et al.: Sex reassaignment surgery, transformation to transwomen Table 1: The clinical details of operated transwomen Serial number of Age HIV status Length of neovagina Complications# Secondary Institutional Score Institutional score of transwomen created (cm) procedure of esthetic outcome* functional outcome** 1 22 − 9 E None 3 3 2 31 + 8.7 E None 3 3 3 36 − 11.5 E None 3 3 4 26 + 12 E None 3 3 5 24 − 9.5 E None 3 3 6 40 − 7.5 E None 3 3 7 30 + 10 E SR 2 2 8 33 + 8 E None 3 3 9 25 − 10.5 E None 3 3 10 33 + 9 E None 3 3 11 24 − 10 E None 3 3 12 41 − 12 E None 3 3 13 28 + 9.5 E None 3 3 14 32 − 10.5 E None 3 3 15 29 − 12 E None 3 3 16 26 + 11 MI+MC+E None 3 3 17 39 − 10.5 E None 3 3 18 35 + 9.8 E None 3 3 19 27 + 9 E None 3 3 20 21 − 8.6 E None 3 3 21 33 + 10 E None 3 3 22 34 − 8.5 E None 3 3 23 38 + 9.8 MI+MC+E None 3 3 24 32 − 8 E None 3 3 25 39 + 10.2 E None 3 3 26 24 + 12 E None 3 3 27 32 + 9.2 E None 3 3 28 28 − 10 E None 3 3 29 35 − 9 E None 3 3 30 30 + 9.5 E None 3 3 Average 31.5 9.8 2.9 2.9 #All these were minor complications managed conservatively except SR in one individual. *The following institutional grading system was used for the assessment of esthetic outcome assigned at the end of an average follow up period of 18 months. Grade 1: Poor outcome-Hyper pigmented/hypo pigmented widened scar; Ill-defined introitus; severely distorted submerged clitoris; severely contracted neo-vaginal pouch. Grade 2: Intermediate outcome-Scars hypertrophic; introitus moderately defined; moderately projected clitoris on the crural mount; Mild to moderately contracted neo-vaginal pouch. Grade 3: Excellent outcome-Imperceptible scar merged in the esthetic subunits of external genitalia; well-defined introitus; desired clitoral projection at the proximal end of the introitus commissure, hooded by the scrotal flap and degloved penile flap junction; capacious vaginal introitus. **The following institutional grading system was used for the assessment of functional outcome assigned at the end of an average follow up period of 18 months. Grade 1: Poor outcome-Painful clitoris and scars with no ergogenic response; poor, distorted urinary stream with external urethral meatal stenosis; inadequate Severely contracted vagina causing dyspareunia.
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