Male Perineogenital 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 (0.60 mm), su- and the remain two neglected areas perficial (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 , , work in this area is necessary. and perineal fat and lateral spermatic-scrotal ), 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 , 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 , (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) . (Above, right) Deep external pudendal system with the deep external 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 . 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 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 . (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) 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, (6) internal posterior scrotal arteries, (7) external posterior scrotal arteries, (8) transperineal vessel, (9) funicular artery, (10) vascular circuit around the base of the penis, (11) bulbocavernosus muscle, and (12) scrotal-spermatic fascias. 1304 PLASTIC AND RECONSTRUCTIVE SURGERY, April 1, 2002 medially over the spermatic cord and ar- erally toward the deep external pudendal ve- riving at the base of the penis in a hori- nous system or ventrally toward the infraum- zontal path from the origin of the deep bilical venous plexus and both superficial external pudendal artery to the penile- inferior epigastric and external pudendal ve- pubic angle (the terminal branches to- nous systems just over the abdominal Scarpa ward the base and dorsum of the penis, fascia (Fig. 1). ventral scrotal septum, perineal fat lo- cated between the penis and spermatic Vascular Anastomotic Circuits cord, and the anteromedial spermatic- In all eight specimens studied, three termi- scrotal fascia). nal vascular anastomotic zones were identified b. External anterior scrotal arteries extend- (Fig. 1) as follows: ing along the lateral (the termi- nal branches nourish the anterolateral 1. Base of the penis. This vascular circuit is spermatic-scrotal fascia and the soft tis- basically formed by the bilateral confluence sues of the inguinocrural regions). of the terminal branches of the internal 2. Superficial perineal artery, a terminal anterior scrotal arteries, funicular arteries, branch of the and internal posterior scrotal arteries. In which superficially to the perineal superfi- addition, fine terminal branches of the su- cial transverse muscle and the superficial perficial external pudendal artery often de- perineal aponeurosis, lateral to the bulbo- scend toward the penopubic skin fold. cavernous muscle and 1 to 1.5 cm distant 2. Scrotal septum and perineal fat. This circuit from the middle perineal raphe, gives off is composed of afferent vessels, basically branches at the scrotal space between the from the internal posterior scrotal arteries, external spermatic fascia and the tunica dar- and also by additional blood supply from tos. These terminal vessels are as follows: distal branches of the internal anterior scro- a. Internal posterior scrotal arteries that tal, transperineal, and funicular arteries. course along each side of the middle 3. Lateral spermatic-scrotal fascia. Adhered in- scrotal raphe (the terminal branches timally to the external and internal spermat- nourishing the dorsal scrotal septum, ic-scrotal fascias, the internal and external posteromedial spermatic-scrotal fascia, pudendal arterial systems branch off form- and the perineal fat). ing, respectively, a dorsal and ventral ar- b. External posterior scrotal arteries (the borization pattern or a vascular mesh from distal branches nourishing the postero- the proximal to the distal scrotal sac. This lateral spermatic-scrotal fascia). anastomotic circuit is well defined and par- c. Transperineal arteries, originating from ticularly important at the lateral portion of the internal posterior scrotal arteries or the scrotal sac, and it is basically formed by directly from the superficial perineal ar- the anterior and lateral branches of the tery, crossing transversally over the dorsal deep external pudendal artery and the lat- surface of the bulbocavernous muscle, es- eral and posterior branches of the superfi- tablishing vascular interconnections be- cial perineal artery. This represents an anas- tween both superficial perineal pedicles. tomotic circuit between the lateral terminal 3. Funicular artery, a proximal branch of the branches of both pudendal systems, the in- deep inferior epigastric artery that, crossing ternal and the external. Secondary muscu- below the inguinal ligament, comes to the locutaneous perforants from the medial ad- anterior perineum joined to the surface of ductor muscle (lateral femoral circumflex the spermatic cord giving off terminal artery) and gracilis muscle (obturator ar- branches to the cord, the base of the penis, tery) complete this vascular circuit. Both perineal fat, and the posteromedial sper- anterior and posterior scrotal arteries are matic-scrotal fascia. located between the spermatic-scrotal fas- cias and the muscle of the scrotum Venous Drainage of the Anterior Perineal Region (the so-called scrotal space). There are venae comitantes to the three main arterial axes as previously described, al- Arterial Diameters though superficial cutaneous venous drainage Accurate measurement of the internal arte- of the penile shaft may basically either go lat- rial diameters was accomplished by means of Vol. 109, No. 4 / MALE PERINEOGENITAL ANATOMY 1305 image-system analysis, obtaining the following jacent scrotal-perineal skin. Complete eleva- average calibers: deep external pudendal ar- tion of this flap requires transection of the tery, 0.60 mm; superficial perineal artery, 0.50 proximal perforator of the gracilis muscle, lo- mm; and funicular artery, 0.37 mm. In all eight cated near the ischiopubic bone, and coming specimens, the results on both right and left from the obturator artery. sides were homogeneous. The anterior half of the lateral scrotal- perineal flaps (over the ischiopubic bony rami) Vascular Injection Studies has a direct vascularization pattern formed by Cannulation of the deep external pudendal anastomosis with the external anterior scrotal artery at its origin from the femoral artery was arteries, terminal branches of the deep exter- carried out in two fresh cadavers, and 20 ml of nal pudendal artery. To avoid injuries to these methylene blue was injected to visualize the vessels, it is necessary to elevate the adductor stained cutaneous pattern and the potential muscle aponeurosis at the deep plane of the extension of its angiosome (Fig. 2). lateral scrotal-perineal flap, cauterizing the Penile Shaft Cutaneous Blood Supply fine myocutaneous perforators piercing the ad- ductor muscle and coming from the lateral The previously described vascular circuit femoral circumflex artery. around the base of the penis was identified and The lateral scrotal-perineal flaps may be ven- dissected in eight cadavers (Figs. 1 and 2). This trally extended to the deep external pudendal circuit is basically responsible for the nourish- angiosome, although we advise not going be- ing system of the penile cutaneous coverage, yond the greater saphenous vein distally. Cuta- with additional fine dorsal afferent vessels from neous nerves coming from the internal puden- the terminal branches of the superficial exter- dal nerve accompany the lateral scrotal- nal pudendal artery. The vessels coming from perineal vessels, so the posterior one-third of proximally (base) to distally (), are lo- the flaps is sensate. cated in the areolar connective tissue (superfi- cial penile fascia) under the dartos and the penile skin; the venous system is located super- Penile Glans Neurovascularization ficially with respect to the superficial cutaneous In all our dissections, we found the typically arteries of the penis (terminal branches of the described double neuroarterial system with a internal anterior scrotal arteries), basically paired on the dorsal skin with further fine common venous drainage (Fig. 2). Emerging branches coming to the lateral and ventral cu- from the distal Alcock’s canal approximately taneous coverage of the penis. 1.5 cm from the pubic symphysis on both sides are paired neuroarterial pedicles—terminal Lateral Scrotal-Perineal Paired Flaps structures from the internal pudendal pedi- The wall of the scrotum is composed of the cle—running along the penis beneath Buck’s following layers, starting at the surface: skin, fascia and over the albuginea of the corpora dartos, external spermatic fascia, cremaster, in- cavernosa. The deep dorsal venous system is ternal spermatic fascia, and vaginal (Fig. 2). composed of a unique vein in the middle of The vascular and topographic study of the soft the penile dorsum between both corpora tissues of the anterior perineal region in the cavernosa bodies, although this vessel may male cadavers suggested the possibility of ele- divide proximally at the decussation of the vation of lateral scrotal-perineal paired flaps, crura and also give off one or two perforants posteriorly pedicled and connected to the su- with the superficial suprapubic venous plexus. perficial perineal neurovascular pedicle (exter- In most specimens, the neurovascular struc- nal posterior scrotal arteries). The posterior tures on the dorsum of the penis are located half of these flaps (under the ischiopubic bony according to the palindrome “NAVAN” rami) has a fasciocutaneous vascularization (nerve-artery-vein-artery-nerve). pattern with the following histologic strata: the Finally, the deep dorsal arteries of the penis superficial and medial (Colles’ fascia) perineal give off short perforants that pierce the albug- aponeuroses including the neurovascular pedi- inea and bilateral lateral branches, which form cle, the posterolateral spermatic-scrotal fascias, a deep vascular circuit around the penis. The the gracilis muscle aponeurosis, the smooth dorsal nerves run over these circumflex vessels muscular fibers of the dartos, and the supraad- from proximal to distal. 1306 PLASTIC AND RECONSTRUCTIVE SURGERY, April 1, 2002

FIG.2.(Above, left) Intraarterial injection (methylene blue) of the deep external pudendal artery showing the angiosome that can potentially be captured by flaps based on the terminal branches of the internal pudendal vessels. (Above, right) The skin of lateral scrotal-perineal fasciocutaneous flaps has been removed, showing the lateral scrotal-spermatic fascias, the lateral anas- tomotic circuit, and the anterior extension of these flaps. (Center, left) In a fresh cadaver, the deep dorsal neurovascular pedicles of the penis have been dissected, opening Buck’s fascia to show the anatomic disposition following the palindrome “NAVAN” (nerve-artery-vein-artery-nerve). (Center, right) A neurovascular island flap of the has been elevated, skeletonizing the Vol. 109, No. 4 / MALE PERINEOGENITAL ANATOMY 1307 Rectovesical Space frequent objects of investigation, and many dif- Midline sagittal sections of the whole ferent perineal axial flaps have been used for in two male cadavers were carried out to study reconstruction of congenital malformations, the length of this virtual cavity, and the “criti- for acquired genital defects, and for sex reas- cal” key points of dissection of the rectovesical signment surgery. space (Fig. 2). The mean distance from the In female patients, and as far as we are perineal skin to the peritoneal inferior reflec- aware, Morton et al.5 in 1986 were the first to tion (Douglas pouch) was 11.5 cm, addition of use labioscrotal fasciocutaneous flaps based on further length by means of blunt digital dissec- the superficial perineal artery for treatment of tion being difficult. The key point for adequate severe vaginal stenosis in two patients with ad- opening of this space, without risking perfora- renogenital syndrome. Hagerty et al.6,7 used tion of the and/or the rectum, is care- similar triangular flaps for acquired vaginal de- ful sharp dissection of the rectourethral mus- fects. Wee and Joseph8 in 1989 described the cle. This structure is formed of dense “Singapore flap” or neurovascular pudendal- fibromuscular tissue closely adhering the mem- thigh flap for complete vaginal reconstruction, branous urethra to the anterior convexity of and Woods et al.9 in 1992 used the “modified the rectum ampule, and it is found behind the Singapore flap” for complex postoncologic re- corpus spongiosum 4 to 5 cm deep with respect constructions. Giraldo et al.1,2 described the to the perineal skin. Surgical division of this “Málaga flap” or vulvoperineal fasciocutaneous fibromuscular structure requires sharp dissec- flap for reconstruction of neovaginas in the tion with fine scissors once the two lateral rec- Mayer-Rokitansky-Kuster-Hauser syndrome. tal spaces have been dissected easily by means Further experience has been accumulated by of blunt digital dissection. others who have achieved satisfactory out- DISCUSSION comes with flaps based on the superficial per- ineal artery. The anatomy of the perineum and the gen- In male patients, the terminal vessels of the itals has been well described in classic treatises, internal pudendal vascular system have also although recent studies of its cutaneous vascu- been used for genital reconstructions, basically larization system have been decisive for en- for coverage of acquired perineogenital de- hancement of genital reconstructive surgery. fects and sex reassignment surgery in male-to- However, there has been very little scientific female transsexuals. Since the initial descrip- investigation concerning the exact topo- tion of Jones et al.10 in 1968, many others have graphic anatomy of the main afferent and ef- used the posterior scrotal flap for vaginoplasty ferent vessels of the perineogenital skin, to- 11 gether with their corresponding clinical in male-to-female transsexuals. Huang in applications in the field of surgery. 1995 used two neurovascular inguinopudendal Although many useful genital and parageni- flaps combined with a penile skin flap for vag- tal flaps have been described over the years by inoplasty in sex reassignment surgery. Karim et 12 13 authors who have focused their efforts on this al. and Hage reported a very large and suc- interesting and challenging area, from time to cessful series of vaginoplasties in male transsex- time reconstructions are reported using new uals, adding to the anteriorly based penile cu- genital flaps based on different terminal vessels taneous flap a triangular perineoscrotal middle of the main vascular systems afferent to the flap (3 ϫ 10 cm) to complete the posterior genitoperineal region. During the past two de- neovaginal wall. Knol and Hage14 in 1997 pub- cades, the internal pudendal artery and its ter- lished the infragluteal skin flap, based on the minal branches have possibly been the most anterior perineum, for reconstruction of rec- neurovascular structures. (1) Transversal section of the penis at the bifurcation of the corpora cavernosa, (2) corpora cavernosa, and (3) corpus spongiosum. (Below, left) Sagittal section of a pelvis in a male cadaver. (1) Penis with corpora cavernosa and albuginea, (2) corpus spongiosum or bulb of penis, (3) scrotal septum, (4) anal canal, (5) rectum, (6) , (7) urinary bladder, (8) pubic symphysis, (9) retropubic space with venous plexus, and (10) sigmoid colon. (Below, right) Close-up view of the key points of dissection of the rectovesical space. (1) Corpus spongiosum, (2) rectum, (3) urogenital diaphragm with , (4) rectourethral muscle, (5) anterior wall of the rectum, (6) Denonvilliers aponeurosis, (7) rectovesical space, (8) Douglas pouch, (9) , (10) urinary bladder, (11) interpubic disc, and (12) retropubic space showing section of the deep dorsal vein of the penis and the prostatic vascular plexus. 1308 PLASTIC AND RECONSTRUCTIVE SURGERY, April 1, 2002 tovaginal fistulas in female patients and male- proximal bulbar and bulbomembranous to-female transsexuals. transsphincteric strictures or panurethral As a result of our anatomic study of the strictures. The two latter flaps are also cutaneous angiosomes of the anterior perineal sensate. region in human male cadavers, we consider c. Scrotal-perineal flaps based on the external the following clinical applications to be of posterior scrotal artery. Anatomically and interest: clinically, we have gathered evidence of the possibility of elevation of scrotal-perineal Flaps Based on the Internal Pudendal System flaps20,21 including the scrotal skin, dartos, 1. Cutaneous and fasciocutaneous flaps. and both spermatic and perineal fascias a. Scrotal flaps based on both superficial per- proximally, and the scrotal-inguinal skin ineal arteries. Internal and external poste- and the aponeuroses of the gracilis and rior scrotal arteries are final divisions of the medial adductor muscles distally. The main superficial perineal artery and these termi- vascular system is the external posterior nal vessels nourish the internal pudendal scrotal and the perineal superficial trans- cutaneous angiosome, which is integrated verse arteries. Thus, this is an axial flap, at basically by the posterior half of the scro- least in its posterior two-thirds, whereas the tum and the adjacent crural skin. A cen- circulation at its distal third is guaranteed trally pedicled or island scrotal sensate flap by the “choke” anastomoses between the as large as 5 cm wide by 10 to 12 cm long internal and external pudendal angio- includes the superficial perineal artery to- somes. These flaps retain sensation at their gether with its internal and external poste- proximal segments. rior scrotal arteries and complementary d. Paraperineal flaps based on the perineal vascularization from the superficial peri- superficial transverse and inferior rectal ar- neal transverse artery, which runs along the teries. Flaps mainly nourished by these lat- central perineum between the anus and eral vessels branching off the internal pu- the perineum-scrotum; this is the vascular dendal artery have in common the fact that anatomic basis of the biaxial scrotal flaps of they include at their base the soft tissues of Jones,10 Small,15 Eldh,16 and Van Noort and the central perineum. Examples include Nicolai.17 Finally, the cutaneous shaft of the the “lowermost” lotus petal flap described penis can be included in continuity with by Yii and Niranjan22 in 1996, and the sim- the posteriorly pedicled scrotal flap, as de- ilar infragluteal skin flap described by Knol scribed by Edgerton and Bull18 for vagino- and Hage14 in 1997. Only the base of this plasty in sex reassignment surgery, the vas- flap is sensate. cular circuit at the base of the penis being 2. Erectile tissue pedicled or island flaps. responsible for its reliable distal perfusion. a. Dorsally pedicled sensory island flap of the b. Scrotal-perineal flaps based on the internal glans penis. This is a sensate and erectile posterior scrotal arteries. The neurovascu- flap nourished and innervated by the ter- lar inguinopudendal flap as described by minal branches of the internal pudendal Huang11 is typically designed in an oblong artery, the dorsal neurovascular pedicles of fashion, including the inferolateral tissues the penis. This is a well-known flap de- of the scrotal sac and, at its base, the inter- scribed initially by Hinderer23,24 in 1974 for nal posterior scrotal and the superficial neoclitoral reconstructions in the adreno- perineal transverse arteries; this is an axial genital syndrome, and later used by flap, at least in its posterior third, but not Brown25,26 for neoclitoroplasty in male-to- so distally. The central perineoscrotal flap female transsexuals. It is recognized today of Karim et al.12 and Hage13 includes the as the best choice for neoclitoroplasty and scrotal septum, and even though it is very the “gold standard” against which other long and has a limited width (3 ϫ 10 cm), procedures are compared. this is a secure and robust flap because of b. Pedicled urethrobulbar flaps. These flaps its biaxiality specifically nourished by both include the whole urethra, with or without internal posterior scrotal arteries. The the glans, and are vascularized by the bul- same vascular basis is present in the biaxial bar arteries, which are the first branches of epilated scrotal flap, as described by Gil- the common penile artery at the penile Vernet et al.19 in 1997 for treatment of hilum and penetrate the corpus spongio- Vol. 109, No. 4 / MALE PERINEOGENITAL ANATOMY 1309 sum at the 2-o’clock and 10-o’clock posi- Anaya for their support in dissections and help in histologic tions, according to the fine anatomic study preparations. We thank Ian Johnstone for his help with the of Martínez-Piñeiro et al.27 A tubular ure- English language version of the manuscript. thra and corpus spongiosum design with REFERENCES 28 the glans anchored at its distal apex has 1. Giraldo, F., Gaspar, D., González, C., et al. Treatment been used for neoclitoroplasty and a dor- of vaginal agenesis with vulvoperineal fasciocutaneous sally spatulated ureterobulbar flap with the flaps. Plast. Reconstr. Surg. 93: 131, 1994. ventral glans anchored at its distal part29 2. Giraldo, F., Solano, A., Mora, M. J., et al. The Malaga flap for vaginoplasty in the Mayer-Rokitansky-Ku¨ster- for neovaginoplasty with a “pseudocervix” Hauser syndrome: Experience and early-term results. in male-to-female transsexuals. Plast. Reconstr. Surg. 98: 305, 1996. 3. Giraldo, F., Mora, M. J., Solano, A., et al. Anatomic Flaps of the External Pudendal System study of the superficial perineal neurovascular pedi- Dorsally pedicled penile skin flap. This is an cle: Implications in vulvoperineal flap design. Plast. Reconstr. Surg. 99: 100, 1997. axial flap basically nourished by the internal 4. Giraldo, F. Vulvoperineal fasciocutaneous flap for vag- anterior scrotal arteries, terminal branches of inal reconstruction. In B. Strauch, L. O. Vasconez, and the deep external pudendal artery.30 Additional E. J. Hall-Findlay (Eds.), Grabb’s Encyclopedia of Flaps, vascularization comes from the terminal vessels 2nd Ed. Philadelphia: Lippincott-Raven, 1998. Pp. of the posterior scrotal arteries and fine termi- 1461–1465. 5. Morton, K. E., Davis, D., and Dewhurst, J. The use of nal branches of the funicular artery. Therefore, fasciocutaneous flap in vaginal reconstruction. Br. J. this tubular cutaneous flap, either ventrally or Obstet. Gynaecol. 93: 970, 1986. dorsally pedicled, has a robust and secure vas- 6. Hagerty, R. C., Vaughn, T. R., and Lutz, M. H. The cularization formed by distal anastomoses (at perineal artery axial flap. Plast. Reconstr. Surg. 82: 344, the base of the penis) of three different vascular 1988. 7. Hagerty, R. C., Vaughn, T. R., and Lutz, M. H. The systems: deep and superficial external puden- perineal artery axial flap. Ann. Plast. Surg. 31: 28, 1993. dal, internal pudendal, and deep inferior epi- 8. Wee, J. T., and Joseph, V. T. A new technique of vaginal gastric arteries. reconstruction using neurovascular pudendal-thigh When an abdominally pedicled penile shaft flaps: A preliminary report. Plast. Reconstr. Surg. 83: flap is used in transsexual surgery, to achieve 701, 1989. 9. Woods, J. E., Alter, G., Meland, B., and Podratz, K. Ex- maximum neovaginal depth we need a poste- perience with vaginal reconstruction utilizing the rior advancement of this flap from the supra- modified Singapore flap. Plast. Reconstr. Surg. 90: 270, pubic skin to the cavernosa stumps, anchored 1992. with two stitches, placed 2 cm ventrally of the 10. Jones, H. W.,Jr., Schirmer, H. K. A., and Hoopes, J. A penopubic angle, to prevent vascularization sex conversion operation for males with transsexual- ism. Am. J. Obstet. Gynecol. 100: 101, 1968. problems derived from trapping of the afferent 11. Huang, T. T. Twenty years of experience in managing vessels of the penile shaft flap. For many good gender dysphoric patients: I. Surgical management of reasons, this is the most frequently used flap male transsexuals. Plast. Reconstr. Surg. 96: 921, 1995. and the gold standard for neovaginal recon- 12. Karim, R. B., Hage, J. J., Bouman, F. G., et al. Refine- struction in male-to-female transsexuals. Our ments of pre-, intra-, and postoperative care to prevent complications of vaginoplasty in male transsexuals. anatomic study of the anterior perineal region Ann. Plast. Surg. 35: 279, 1995. in male cadavers provides an approximation to 13. Hage, J. J. Vaginoplasty in male-to-female transsexuals the accurate knowledge of the vascular basis of by inversion of penile and scrotal skin. In R. M. Ehrlich the perineogenital skin that may allow easier and G. J. Alter (Eds.), Reconstructive and Plastic Surgery understanding and reliable design and man- of the External Genitalia. Philadelphia: Saunders, 1999. Pp. 294–300. agement of flaps in genital reconstructions and 14. Knol, A. C. A., and Hage, J. J. The infragluteal skin flap: in sex reassignment surgery. A new option for reconstruction in the perineogenital Francisco Giraldo, M.D., Ph.D. area. Plast. Reconstr. Surg. 99: 1954, 1997. Plastic and Reconstructive Unit 15. Small, M. P. Penile and scrotal inversion vaginoplasty Carlos Haya Regional Hospital for male-to-female transsexuals. Urology 29: 593, 1987. 29010 Málaga, Spain 16. Eldh, J. Construction of a neovagina with preservation [email protected] of the glans penis as a clitoris in male transsexuals. Plast. Reconstr. Surg. 91: 895, 1993. 17. Van Noort, D. E., and Nicolai, J. P. A. Comparison of ACKNOWLEDGMENTS two methods of vagina construction in transsexuals. We would like to express our gratitude to Dr. José M. Plast. Reconstr. Surg. 91: 1308, 1993. Smith-Agreda, chief of the I Morphologic Sciences Depart- 18. Edgerton, M. T., and Bull, J. Surgical construction of ment at the Faculty of Medicine, and our fondest apprecia- the vagina and labia in male transsexuals. Plast. Re- tion to Manuel Villena, María D. Villatoro, and María Victoria constr. Surg. 46: 529, 1970. 1310 PLASTIC AND RECONSTRUCTIVE SURGERY, April 1, 2002

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