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Male Perineogenital Anatomy and Clinical Applications in Genital Reconstructions and Male-To-Female Sex Reassignment Surgery

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Male Perineogenital Anatomy and Clinical Applications in Genital Reconstructions and Male-To-Female Sex Reassignment Surgery Male Perineogenital Anatomy and Clinical Applications in Genital Reconstructions and Male-to-Female Sex Reassignment Surgery Francisco Giraldo, M.D., Ph.D., María José Mora, M.D., Ph.D., Ana Solano, M.D., Ph.D., Carlos González, M.D., and Víctor Smith-Fernández, M.D., Ph.D. Málaga, Spain To determine the possibility of providing alternative such evolution, creativeness, and perfectionism surgical techniques for male genital reconstruction and in so short a period of time as has plastic and for male-to-female sex reassignment surgery, the authors undertook an anatomic investigation of the perineogeni- reconstructive surgery. tal region in male cadavers. Anatomic dissection was per- Either as a consequence of the lack of avail- formed on 14 male adult human cadavers (fresh and ability of human cadavers for scientific investi- formalin-preserved) studying the main afferent vessels to gation or difficulties secondary to technical ap- the anterior perineal region and their mean internal di- proaches in the zones concerned, the genitals ameters: deep external pudendal artery (0.60 mm), su- and the perineum remain two neglected areas perficial perineal artery (0.50 mm), and funicular artery (0.37 mm). We established their exact topography, to- of anatomic study, with a relatively limited gether with vascular anatomic variations, main vascular number of publications to date, so that further anastomosis circuits (base of the penis, scrotal septum, work in this area is necessary. and perineal fat and lateral spermatic-scrotal fascia), an- In 1991, we initiated an anatomic investiga- giosomes, anatomy of the rectovesical septum cavity, and tion in female cadavers of perineogenital soft their “critical” key points of dissection. The authors dis- tissues. The findings of these studies enabled cuss the clinical possibility of elevation of a “tree” of pre- viously described paragenital-genital flaps including us to successfully apply new techniques and mainly those based on the terminal branches of the in- approaches in vaginal reconstructive sur- ternal pudendal vascular system, the erectile tissue pedi- gery.1–4 We have since undertaken a similar cled flaps, and finally, flaps of the external pudendal sys- investigation in male cadavers, to determine tem. The authors indicate the concrete vascularization the possibility of providing alternative surgical system for each flap. (Plast. Reconstr. Surg. 109: 1301, techniques to those already described for gen- 2002.) ital reconstruction and for sex reassignment surgery. The main afferent vessels to the skin of the Although gross anatomy is well known genitals and the anterior perineal region in the through classic treatises, most scientific ad- male anatomy are the anterior scrotal arteries, vances in the field of plastic surgery have come which are direct branches from the femoral about as a result of investigation in the area of vascular system; and the posterior scrotal arter- cutaneous vascularization patterns in both hu- ies, which are terminal branches of the super- man cadavers and clinical practice. This re- ficial perineal vessels from the internal iliac search has resulted in impressive progress and vascular system. In addition, there is another development over the past 100 years, and prob- vascular structure which we consider to be rel- ably no other surgical specialty has achieved evant in this field, the funicular artery, a prox- From the Plastic and Reconstructive Unit, “Carlos Haya” Regional Hospital; and the Normal and Pathologic Morphology Department of the Faculty of Medicine, Málaga University. Received for publication May 1, 2001. This work was supported by a grant (Project Exp. 0686/98) from the Fondo de Investigación Sanitaria (FIS), Instituto de Salud Carlos III, Ministerio de Sanidad y Consumo. 1301 1302 PLASTIC AND RECONSTRUCTIVE SURGERY, April 1, 2002 FIG.1.(Above, left) Deep external pudendal system. (1) Deep external pudendal artery, (2) internal anterior scrotal arteries, (3) external anterior scrotal arteries, (4) superficial cutaneous arteries of the penis, (5) great saphenous vein, (6) superficial external pudendal artery, (7) superficial vein draining the penile shaft, (8) deep dorsal neurovascular pedicles of the penis, (9) aponeurosis of the adductor longus muscle, (10) adductor longus muscle, (11) gracilis muscle, and (12) spermatic cord. (Above, right) Deep external pudendal system with the deep external pudendal arteries crossing over the saphenous hiatus. (1) Deep Vol. 109, No. 4 / MALE PERINEOGENITAL ANATOMY 1303 imal branch of the inferior deep epigastric the anatomy of the rectovesical septum, with artery from the external iliac system. identification of the “critical” key points of dis- In this work, we report our experience in a section of the rectovesical virtual space. Neu- series of human dissections of the perineogeni- rovascular structures were dissected bilaterally tal region in male cadavers. We describe the using magnifying glasses (ϫ3.5), and high- main vascular trunks arriving at this region, its resolution photographs of the origin, distribu- exact topography and anatomic variations, and tion, and topography of the vascular structures the principal anastomotic vascular circuits and were taken. their relation with spermatic-scrotal fascias. Arteriectomy specimens 1 cm long were har- The internal diameters of these arteries mea- vested from the proximal segment of the main sured by means of image analysis suggested the arteries (superficial perineal, deep external pu- possibility of elevation of a “tree” of genital dendal, and funicular) to determine their in- flaps based on these vascular axes and their ternal diameters. These arterial specimens terminal branches for applications in genital were processed and image-system analyzed fol- reconstructions and male-to-female sex reas- lowing the same systematic procedure used signment surgery. previously.3 The deep external pudendal artery was isolated and cannulated unilaterally in two MATERIALS AND METHODS cadavers, and its corresponding angiosomes Anatomic dissection was performed on 14 were visualized by means of the intraarterial male adult human cadavers (12 formalin- injection of 20 ml of methylene blue, and preserved and two fresh), useful for teaching the stained cutaneous territories were and investigation, from the Normal and Patho- photographed. logic Morphology Department, Faculty of Med- icine, Málaga University, Spain. External exam- RESULTS ination of the cadavers revealed no scars or anomalies in the perineal, genital, and ingui- Afferent Vessels to the Anterior Perineal Region and nal regions. By means of macro-micro dissec- their Distribution tion, the main afferent and efferent vascular In eight anatomic dissections, the unvarying structures to the skin of the genitals and ante- presence of three main vascular axes was de- rior perineal region were identified. We ana- termined (Fig. 1) as follows: lyzed 16 vascular pedicles (eight right, eight left) of the superficial perineal, deep external 1. Deep external pudendal artery, a direct pudendal, and funicular arteries, and deter- branch of the femoral artery arriving at the mined their relation to certain anatomic land- anterior perineal region, crossing under the marks, their main vascular anastomosis cir- great saphenous hiatus in seven of eight cuits, and the internal diameters of each artery. dissections (87.5 percent), and over this ve- In addition, in six cadavers, angiosomes of the nous structure in one case (12.5 percent) in main cutaneous arteries of the anterior peri- our series. At the spermatic cord the deep neal region were studied, and neurovascular external pudendal artery gives off the structures of the dorsum of the penis, the vas- following: cularization system of the scrotal septum, and a. Internal anterior scrotal arteries crossing external pudendal arteries, (2) internal anterior scrotal arteries, (3) external anterior scrotal arteries, (4) saphenous hiatus, (5) superficial cutaneous arteries of the penile shaft, and (6) right testicle. (Center, left) Superficial perineal neurovascular system. (1) Superficial perineal neurovascular pedicle, (2) external posterior scrotal arteries, (3) internal posterior scrotal arteries, (4) corpus spongiosum, (5) bulbocavernosus muscle, (6) right testicle, (7) left testicle, (8) penis, (9) scrotal-spermatic fascias. (Center, right) Superficial perineal neurovascular system. (1) Superficial perineal neurovascular pedicle, (2) external posterior scrotal arteries, (3) internal posterior scrotal arteries, (4) transperineal vessels communicating both superficial perineal pedicles, and (5) bulbocavernosus muscle. (Below, left) Lateral scrotal-spermatic vascular anastomotic circuit. (1) Deep external pudendal artery, (2) internal anterior scrotal arteries, (3) external posterior anterior arteries, (4) superficial perineal neurovascular pedicle, (5) internal posterior scrotal arteries, (6) external posterior scrotal arteries, (7) lateral scrotal-spermatic fascias, (8) obturator artery perforator, (9) penis, (10) adductor longus muscle, (11) gracilis muscle, and (12) “choke” anastomoses between the external posterior and anterior scrotal arteries. (Below, right) Main afferent vessels to the anterior perineal region and their relations with the scrotal-spermatic fascias. (1) Deep external pudendal artery, (2) internal anterior scrotal arteries, (3) external anterior scrotal arteries, (4) superficial cutaneous artery of the penile shaft, (5) superficial perineal vascular pedicle,
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