The History of Gender-Affirming Vaginoplasty Technique
2022; Elsevier BV; Volume: 165; Linguagem: Inglês
10.1016/j.urology.2022.03.032
ISSN1527-9995
AutoresAndrew J. Zilavy, Richard A. Santucci, Maxx Gallegos,
Tópico(s)Body Image and Dysmorphia Studies
ResumoEvidence of gender variance is present throughout all societies of human history, dating back to the earliest cultures of which we have anthropologic record.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar The phenomenon first came to the attention of modern medicine around the turn of the twentieth century, where it was described as a psychiatric illness by Richard von Krafft-Ebing and other early sexologists.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar,2Stryker S. Transgender History. Seal Press, New York, New York2017Google Scholar With the primordial classification of the condition as a form of delusional disorder, all means of psychotherapy were attempted to convince patients to abandon the belief they were trapped in the wrong sex body and to accept their assigned gender.3Pauly IB. The current status of the change of sex operation.J Nerv Ment Dis. 1968; 147: 460-471Crossref PubMed Scopus (116) Google Scholar Such attempts were widely and consistently ineffective to convert the adult transgender/non-binary (TGNB) patient or to relieve their suffering, which was regularly severe enough to drive patients to genital amputation or suicide.3Pauly IB. The current status of the change of sex operation.J Nerv Ment Dis. 1968; 147: 460-471Crossref PubMed Scopus (116) Google Scholar,4James SE Herman JL Rankin S Keisling M Mottet L Anafi M. The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality, Washington, DC2016: 95-102Google Scholar Therapeutic benefit was first achieved using the affirmative treatment pathway, originally pioneered in Magnus Hirschfeld's Institute of Sexual Research in 1919 in Berlin, until it was sacked and its library burned by the Nazi party in 1933.2Stryker S. Transgender History. Seal Press, New York, New York2017Google Scholar The endocrinologist Harry Benjamin successfully championed comprehensive transgender healthcare beginning in the early 1950s in San Francisco.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar,2Stryker S. Transgender History. Seal Press, New York, New York2017Google Scholar His affirmative treatment pathway supported patients' case-by-case need for social transition, need for the newly available cross-sex hormones, and even the need to refer patients for gender-affirmation surgery where appropriate.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar,2Stryker S. Transgender History. Seal Press, New York, New York2017Google Scholar During this time there were scarce surgeons offering gender-affirming vaginoplasty (GAV): for example the American trained Plastic surgeon Fernando Ortiz Monasterio of Mexico,5Cairns T de Villiers W. Vaginoplasty.S Afr Med J. 1980; 57: 50-55PubMed Google Scholar,6Gallegos E. Fernando Ortiz Monasterio, cirujano plastico: el uico limite es la imaginacion. La Jornada (Mexico City). Published online 1997:12.Google Scholar the British Urologist Peter Philip,7King D Ekins R. Pioneers of transgendering: John Randell, 1918-1982.in: GENDYS 2002: The Seventh International Gender Dysphoria Conference. 2002Google Scholar the American Urologist Elmer Belt,2Stryker S. Transgender History. Seal Press, New York, New York2017Google Scholar,8Hage JJ Karim RB Laub DR. On the origin of pedicled skin inversion vaginoplasty: life and work of Dr Georges Burou of Casablanca.Ann Plast Surg. 2007; 59: 723-729Crossref PubMed Scopus (26) Google Scholar and most notably the French Gynecologist Dr. Georges Burou.8Hage JJ Karim RB Laub DR. On the origin of pedicled skin inversion vaginoplasty: life and work of Dr Georges Burou of Casablanca.Ann Plast Surg. 2007; 59: 723-729Crossref PubMed Scopus (26) Google Scholar So few were willing to risk performing the operation due to fear of patient regret and retribution, professional shame and legal consequence.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar,2Stryker S. Transgender History. Seal Press, New York, New York2017Google Scholar It was well understood that any surgeon who performed GAV might be charged with criminal mayhem, the purposeful maiming of a patient.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar,2Stryker S. Transgender History. Seal Press, New York, New York2017Google Scholar The Danish-American trans woman Christine Jorgensen, who had become famous for undergoing a gender-affirming surgery in 1952, used her growing influence to create "as much good publicity as possible for the sake of all those to whom I am a representation of themselves." 2Stryker S. Transgender History. Seal Press, New York, New York2017Google Scholar,9Fogh-Andersen P. Transvestism and trans-sexualism; surgical treatment in a case of auto-castration.Acta Med Leg Soc (Liege). 1956; 9: 33-40PubMed Google Scholar She fit into the role of the classic American female.2Stryker S. Transgender History. Seal Press, New York, New York2017Google Scholar She presented herself with poise and because of her the stereotype of the transgender person as a mentally ill, sexual-deviant began to fade.2Stryker S. Transgender History. Seal Press, New York, New York2017Google Scholar She became Benjamin's patient as he used her spotlight to further his mission to facilitate greater access to transgender medical and surgical care.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar,2Stryker S. Transgender History. Seal Press, New York, New York2017Google Scholar By the early 1960s, in part due to referrals by Christian Hamburger and Christine Jorgensen, Benjamin had become the mecca for TGNB patients seeking hormonal and surgical care.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar,2Stryker S. Transgender History. Seal Press, New York, New York2017Google Scholar He referred patients to Burou and the few other known surgeons.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar As he toured the country giving lectures on transgender medicine, his network of potential surgeons grew.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar Despite this, his ability to connect his patients to surgeons was still lacking.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar By 1964, only 31 of his patients had received GAV.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar Transgender medicine was a taboo fringe science and little progress occurred in the field until 1963, when Benjamin met his most significant patient since Christine Jorgensen.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar,2Stryker S. Transgender History. Seal Press, New York, New York2017Google Scholar Reed Erikson was an American transman and millionaire philanthropist.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar,2Stryker S. Transgender History. Seal Press, New York, New York2017Google Scholar He founded and personally financed the Erickson Educational Foundation (EEF) in 1964; the first international transgender healthcare network.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar,2Stryker S. Transgender History. Seal Press, New York, New York2017Google Scholar The EEF supported Benjamin's mission to link transgender patients to capable providers, and it directly funded almost every aspect of research and applied science related to transgender care in the 1960s and 1970s.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar,2Stryker S. Transgender History. Seal Press, New York, New York2017Google Scholar The 1970′s were a time of expansion for genital gender-affirmation surgery.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar,2Stryker S. Transgender History. Seal Press, New York, New York2017Google Scholar The opening of the Johns Hopkins Gender Identity Clinic (GIC) in 1966 was closely followed by the establishment of GICs in the United States at The University of Minnesota, The University of Washington Seattle, Stanford, University of California Los Angeles, University of Texas Galveston and Northwestern.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar-3Pauly IB. The current status of the change of sex operation.J Nerv Ment Dis. 1968; 147: 460-471Crossref PubMed Scopus (116) Google Scholar,10Huang TT. Twenty years of experience in managing gender dysphoric patients: I. Surgical management of male transsexuals.Plast Reconstr Surg. 1995; 96: 921-930Crossref PubMed Scopus (37) Google Scholar GICs were also founded in the Netherlands and Charing Cross Hospital in London.7King D Ekins R. Pioneers of transgendering: John Randell, 1918-1982.in: GENDYS 2002: The Seventh International Gender Dysphoria Conference. 2002Google Scholar,11Freundt I. Colocolpopoiesis: The Use Of Sigmoid Colon In The Treatment Of Conditions Associated With Absence Of The Vagina. Erasmus University Rotterdam, Rotterdam, Netherlands1994: 31-66Google Scholar The unquestionable reputation of these combined institutions removed the previous dread of retribution from the minds of potential GAV surgeons.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar With new patient selection protocols, the risk of post-operative regret was decreasing.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar Surgeons no longer had cause to fear criminal mayhem charges as the operation was now part of legitimate medical science.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar The positive public image of trans woman Christine Jorgensen, Harry Benjamin's growing provider network, coupled with the arrival of the first high-volume provider since Burou, together marked the beginning of the renaissance in transgender surgical care.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar Stanley Biber, a rural community general surgeon, first performed GAV in 1969 on a Benjamin patient utilizing operative reports he'd requested from Hopkins.12Bradley-Springer L. Interview with marci bowers, MD.J Assoc Nurses AIDS Care. 2010; 21: 186-191Crossref PubMed Scopus (2) Google Scholar In the small town of Trinidad, Colorado, from 1969 to 2003, Biber would perform an estimated 4000 GAV operations, including complex revision work.1Green R Money J. Transsexualism and Sex Reassignment.2nd ed. The Johns Hopkins University Press, Baltimore, Maryland1969Google Scholar,12Bradley-Springer L. Interview with marci bowers, MD.J Assoc Nurses AIDS Care. 2010; 21: 186-191Crossref PubMed Scopus (2) Google Scholar,13Laub DR Laub Jr., DR S Biber Vaginoplasty for gender confirmation.Clin Plast Surg. 1988; 15: 463-470Abstract Full Text PDF PubMed Google Scholar In 1977 the American psychologist-sexologist Paul A. Walker reorganized the foundation and the EEF became known as the Janus Information Facility (JIF).14Walker PA. Memo to: persons interested in the harry benjamin international gender dysphoria association. Published online 1979. https://www.wpath.org/about/historyGoogle Scholar In 1979, Walker and an elected committee of 6 others renamed and expanded the JIF into the Harry Benjamin International Gender Dysphoria Association (HBIGDA).14Walker PA. Memo to: persons interested in the harry benjamin international gender dysphoria association. Published online 1979. https://www.wpath.org/about/historyGoogle Scholar This committee published the first Standards of Care (SOC) for transgender health.14Walker PA. Memo to: persons interested in the harry benjamin international gender dysphoria association. Published online 1979. https://www.wpath.org/about/historyGoogle Scholar The SOC set forth by the HBIGDA provided a practical set of guidelines to help determine who was a candidate for GAV.2Stryker S. Transgender History. Seal Press, New York, New York2017Google Scholar,14Walker PA. Memo to: persons interested in the harry benjamin international gender dysphoria association. Published online 1979. https://www.wpath.org/about/historyGoogle Scholar In 2007, the HBIGDA was renamed the World Professional Association for Transgender Health (WPATH) and their published guidelines are still considered the standard of care in transgender medicine.2Stryker S. Transgender History. Seal Press, New York, New York2017Google Scholar Opponents of the affirmative treatment pathway for TGNB patients argued that these irreversible, morbid treatments did not truly help patients.15Nutt AE. Long shadow cast by psychiatrist on transgender issues finally recedes at Johns Hopkins.Washinton Post. 2017; https://www.washingtonpost.com/national/health-science/long-shadow-cast-by-psychiatrist-on-transgender-issues-finally-recedes-at-johns-hopkins/2017/04/05/e851e56e-0d85-11e7-ab07-07d9f521f6b5_story.htmlGoogle Scholar They held the archaic position that TGNB patients suffered from a form of delusional disorder and that all aspects of the affirmative treatment pathway, most notably surgery, were inappropriate in the treatment of a purely psychiatric illness.15Nutt AE. Long shadow cast by psychiatrist on transgender issues finally recedes at Johns Hopkins.Washinton Post. 2017; https://www.washingtonpost.com/national/health-science/long-shadow-cast-by-psychiatrist-on-transgender-issues-finally-recedes-at-johns-hopkins/2017/04/05/e851e56e-0d85-11e7-ab07-07d9f521f6b5_story.htmlGoogle Scholar The poster child of this influential opposition movement was Paul R. McHugh.15Nutt AE. Long shadow cast by psychiatrist on transgender issues finally recedes at Johns Hopkins.Washinton Post. 2017; https://www.washingtonpost.com/national/health-science/long-shadow-cast-by-psychiatrist-on-transgender-issues-finally-recedes-at-johns-hopkins/2017/04/05/e851e56e-0d85-11e7-ab07-07d9f521f6b5_story.htmlGoogle Scholar In 1979, wielding his position as the chair of Psychiatry at Johns Hopkins Hospital, he successfully closed the Hopkins GIC.15Nutt AE. Long shadow cast by psychiatrist on transgender issues finally recedes at Johns Hopkins.Washinton Post. 2017; https://www.washingtonpost.com/national/health-science/long-shadow-cast-by-psychiatrist-on-transgender-issues-finally-recedes-at-johns-hopkins/2017/04/05/e851e56e-0d85-11e7-ab07-07d9f521f6b5_story.htmlGoogle Scholar This resulted in a confused, hostile atmosphere for transgender healthcare in the United States and accordingly the growth of the field plateaued and was effectively stifled for at least 3 decades.15Nutt AE. Long shadow cast by psychiatrist on transgender issues finally recedes at Johns Hopkins.Washinton Post. 2017; https://www.washingtonpost.com/national/health-science/long-shadow-cast-by-psychiatrist-on-transgender-issues-finally-recedes-at-johns-hopkins/2017/04/05/e851e56e-0d85-11e7-ab07-07d9f521f6b5_story.htmlGoogle Scholar,16Terris-Feldman A Chen A Poudrier G Garcia M How accessible is genital gender-affirming surgery for transgender patients with commercial and public health insurance in the United States?.Sex Med. 2020; 8: 664-672Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Expert transgender healthcare providers, who saw patients benefit from gender-affirmative social transition, hormones and surgery debated the opposition camp, asking the critical question: "what meaningful alternative help have you been able to offer the transsexual patient?"17Edgerton MT. The role of surgery in the treatment of transsexualism.Ann Plast Surg. 1984; 13: 473-481Crossref PubMed Scopus (26) Google Scholar Eventually, the answer from the opposition to this question became apparent, they had no meaningful alternative to the affirmative treatment pathway.15Nutt AE. Long shadow cast by psychiatrist on transgender issues finally recedes at Johns Hopkins.Washinton Post. 2017; https://www.washingtonpost.com/national/health-science/long-shadow-cast-by-psychiatrist-on-transgender-issues-finally-recedes-at-johns-hopkins/2017/04/05/e851e56e-0d85-11e7-ab07-07d9f521f6b5_story.htmlGoogle Scholar Gradually, the influence of the opposition waned and the hostile environment lifted.15Nutt AE. Long shadow cast by psychiatrist on transgender issues finally recedes at Johns Hopkins.Washinton Post. 2017; https://www.washingtonpost.com/national/health-science/long-shadow-cast-by-psychiatrist-on-transgender-issues-finally-recedes-at-johns-hopkins/2017/04/05/e851e56e-0d85-11e7-ab07-07d9f521f6b5_story.htmlGoogle Scholar In 2017, Hopkins moved beyond the anti-transgender views of McHugh and reopened the GIC.15Nutt AE. Long shadow cast by psychiatrist on transgender issues finally recedes at Johns Hopkins.Washinton Post. 2017; https://www.washingtonpost.com/national/health-science/long-shadow-cast-by-psychiatrist-on-transgender-issues-finally-recedes-at-johns-hopkins/2017/04/05/e851e56e-0d85-11e7-ab07-07d9f521f6b5_story.htmlGoogle Scholar This occurred within the context of a larger phenomenon, a long overdue expansion of gender-affirming healthcare providers and surgeons.15Nutt AE. Long shadow cast by psychiatrist on transgender issues finally recedes at Johns Hopkins.Washinton Post. 2017; https://www.washingtonpost.com/national/health-science/long-shadow-cast-by-psychiatrist-on-transgender-issues-finally-recedes-at-johns-hopkins/2017/04/05/e851e56e-0d85-11e7-ab07-07d9f521f6b5_story.htmlGoogle Scholar,16Terris-Feldman A Chen A Poudrier G Garcia M How accessible is genital gender-affirming surgery for transgender patients with commercial and public health insurance in the United States?.Sex Med. 2020; 8: 664-672Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Recent United States and Dutch data show that TGNB persons compose an estimated 0.4%-1.1% of the population.18Meerwijk EL Sevelius JM. Transgender population size in the United States: a meta-regression of population based probability samples.Am J Public Health. 2017; 107: 1-8Crossref PubMed Scopus (345) Google Scholar 12% of American trans women have undergone GAV and an additional 54% desire GAV.4James SE Herman JL Rankin S Keisling M Mottet L Anafi M. The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality, Washington, DC2016: 95-102Google Scholar Of those seeking insurance coverage for GAV, 55% are denied and 21% were covered, but had no GAV surgeons available in their network.4James SE Herman JL Rankin S Keisling M Mottet L Anafi M. The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality, Washington, DC2016: 95-102Google Scholar As the demand for GAV continues to rise, so will the need for qualified GAV providers.16Terris-Feldman A Chen A Poudrier G Garcia M How accessible is genital gender-affirming surgery for transgender patients with commercial and public health insurance in the United States?.Sex Med. 2020; 8: 664-672Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar In this new era of gender-affirming surgery, where a growing number of urologic, plastic, gynecologic and general surgeons are becoming specialty trained in gender-affirmation surgery, the fascinating history of GAV is more important than ever.16Terris-Feldman A Chen A Poudrier G Garcia M How accessible is genital gender-affirming surgery for transgender patients with commercial and public health insurance in the United States?.Sex Med. 2020; 8: 664-672Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar The traditional history that persists to this day has left behind several significant events and persons.19Bizic M Kojovic V Duisin D et al.An overview of neovaginal reconstruction options in male to female transsexuals.Scientific World J. 2014; 14: 1-8Crossref Scopus (36) Google Scholar,20Goldwyn R. History of attempts to form a vagina.Plast Reconstr Surg. 1977; 59: 319-329Crossref PubMed Scopus (68) Google Scholar We present an updated, overview of the history of GAV technique based on rigorous re-review of the primary literature, historical research and historical discovery.49Zilavy A. Figure 2.Peritoneal Flap Gender-Affirming Vaginoplasty. 2021; Google Scholar, 50Zilavy A. Random Medial Thigh Flaps and Inguinopudendal Pedicled Fasciocutaneous Flaps. 2021; Google Scholar, 51Zilavy A. Split Thickness Skin Graft. 2021; Google Scholar, 52Zilavy A. Penile Inversion Vaginoplasty. 2021; Google Scholar, 53Zilavy A. Bowel Substitution Vaginoplasty. 2021; Google Scholar, 54Zilavy A. Figure 1.Timeline. 2021; Google ScholarFigure 249Zilavy A. Figure 2.Peritoneal Flap Gender-Affirming Vaginoplasty. 2021; Google Scholar Peritoneal flaps are mobilized, pulled down to be anastomosed to the skin of the distal canal, and the peritoneal apices are coapted.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Descriptions of surgical interventions to restore form and function for vaginal obstruction or non-functioning vagina, be it from imperforate hymen, vaginal septum, vaginal hypoplasia or vaginal agenesis, date back to Greek antiquity.20Goldwyn R. History of attempts to form a vagina.Plast Reconstr Surg. 1977; 59: 319-329Crossref PubMed Scopus (68) Google Scholar Incision of the obstruction or sharp dissection for creation of a canal in the pre-aseptic era generally resulted in injury to the urethra, bladder or rectum with fistula or entry into the peritoneal cavity and death from infection.20Goldwyn R. History of attempts to form a vagina.Plast Reconstr Surg. 1977; 59: 319-329Crossref PubMed Scopus (68) Google Scholar Even with improved safety in canal dissection due to increased surgical prowess and adoption of aseptic technique, simple perineal rectovesical canal dissection for creation of a neovagina proved insufficient.20Goldwyn R. History of attempts to form a vagina.Plast Reconstr Surg. 1977; 59: 319-329Crossref PubMed Scopus (68) Google Scholar It was observed that without maintenance the cavity uniformly stenosed or obliterated.20Goldwyn R. History of attempts to form a vagina.Plast Reconstr Surg. 1977; 59: 319-329Crossref PubMed Scopus (68) Google Scholar Therefore, indwelling neovaginal molds with progressive dilation and epithelialization over a period of months following dissection were attempted in cis-women, but these too with dissatisfying results; stenosis, incomplete epithelialization and excessive granulation tissue.20Goldwyn R. History of attempts to form a vagina.Plast Reconstr Surg. 1977; 59: 319-329Crossref PubMed Scopus (68) Google Scholar In 1872, C.L. Heppner was the first to line the newly dissected neovaginal cavity of a cisgender woman with random skin flaps.21Kroemer P. Die plastische neubildung der scheide bei par tiellem und totalem defekt.Praktische Ergebnisse der Geburtshilfe und Gynäkologie. 1912; 5-6 (jahrg): 89-120Google Scholar The distal canal was lined with advancement flaps from the rectovesical septum and the proximal canal was lined with thigh flaps.21Kroemer P. Die plastische neubildung der scheide bei par tiellem und totalem defekt.Praktische Ergebnisse der Geburtshilfe und Gynäkologie. 1912; 5-6 (jahrg): 89-120Google Scholar Random skin flaps from labia, perineum and buttock donor sites have also been described.20Goldwyn R. History of attempts to form a vagina.Plast Reconstr Surg. 1977; 59: 319-329Crossref PubMed Scopus (68) Google Scholar,21Kroemer P. Die plastische neubildung der scheide bei par tiellem und totalem defekt.Praktische Ergebnisse der Geburtshilfe und Gynäkologie. 1912; 5-6 (jahrg): 89-120Google Scholar The early days of random skin flap surgery were guided by primitive knowledge.22Hashimoto I Abe Y Ishida S et al.Development of skin flaps for reconstructive surgery: random pattern flap to perforator flap.J Med Invest. 2016; 63: 159-162Crossref PubMed Scopus (25) Google Scholar It was understood that a random connection between the flap and the body must be maintained for blood supply.22Hashimoto I Abe Y Ishida S et al.Development of skin flaps for reconstructive surgery: random pattern flap to perforator flap.J Med Invest. 2016; 63: 159-162Crossref PubMed Scopus (25) Google Scholar Surgeons realized that random skin flaps of large size or irregular shape tended to suffer ischemic loss, so rigid flap length-to-width ratios were followed.22Hashimoto I Abe Y Ishida S et al.Development of skin flaps for reconstructive surgery: random pattern flap to perforator flap.J Med Invest. 2016; 63: 159-162Crossref PubMed Scopus (25) Google Scholar Knowledge began to accumulate regarding methods for increased skin flap survival, for example the observation that the intact skin of musculocutaneous flaps had excellent survival.23Ponten B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg.Br J Plast Surg. 1981; 34: 215-220Abstract Full Text PDF PubMed Scopus (568) Google Scholar Through insights derived from such observations, modern skin flap surgery developed.22Hashimoto I Abe Y Ishida S et al.Development of skin flaps for reconstructive surgery: random pattern flap to perforator flap.J Med Invest. 2016; 63: 159-162Crossref PubMed Scopus (25) Google Scholar Ponten popularized the pedicled fasciocutaneous flap (PFCF) in 1981, a culmination of decades of combined experience in the plastic surgery community that described principles for creation of well vascularized skin flaps.22Hashimoto I Abe Y Ishida S et al.Development of skin flaps for reconstructive surgery: random pattern flap to perforator flap.J Med Invest. 2016; 63: 159-162Crossref PubMed Scopus (25) Google Scholar,23Ponten B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg.Br J Plast Surg. 1981; 34: 215-220Abstract Full Text PDF PubMed Scopus (568) Google Scholar These principles included dissection of appropriately thick flaps composed of cutis, subcutaneous tissue and fascia.23Ponten B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg.Br J Plast Surg. 1981; 34: 215-220Abstract Full Text PDF PubMed Scopus (568) Google Scholar Greater understanding of skin vascular pedicle anatomy and preservation of the subcutaneous and fascial vascular network increased PFCF survival.22Hashimoto I Abe Y Ishida S et al.Development of skin flaps for reconstructive surgery: random pattern flap to perforator flap.J Med Invest. 2016; 63: 159-162Crossref PubMed Scopus (25) Google Scholar,23Ponten B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg.Br J Plast Surg. 1981; 34: 215-220Abstract Full Text PDF PubMed Scopus (568) Google Scholar Cairns and De Villiers first demonstrated random skin flaps for revision of stenotic neovagina in the transgender population as early as 1977 using random medial thigh flaps.5Cairns T de Villiers W. Vaginoplasty.S Afr Med J. 1980; 57: 50-55PubMed Google Scholar Ted Huang described use of inguinopudendal PFCFs based on superficial branches of the internal pudendal artery.10Huang TT. Twenty years of experience in managing gender dysphoric patients: I. Surgical management of male transsexuals.Plast Reconstr Surg. 1995; 96: 921-930Crossref PubMed Scopus (37) Google Scholar He demonstrated successful outcomes in 109 primary GAV cases from 1978 to 1992.10Huang TT. Twenty years of experience in managing gender dysphoric patients: I. Surgical management of male transsexuals.Plast Reconstr Surg. 1995; 96: 921-930Crossref PubMed Scopus (37) Google Scholar Mukai et al reported 15 cases of GAV utilizing inguinopudendal flap from 2010 to 2016, noting the continued feasibility of the technique.24Mukai Y Watanabe T Sugimoto M Kimata Y Namba Y. Vaginoplasty with a pudendal-groin flap in male-to-female transsexuals.Acta Med Okayama. 2017; 71: 399-405PubMed Google Scholar Though effective, donor site scarring and morbidity of PFCF is significant.19Bizic M Kojovic V Duisin D et al.An overview of neovaginal reconstruction options in male to female transsexuals.Scientific World J. 2014; 14: 1-8Crossref Scopus (36) Google Scholar These flaps lack self-lubrication and can be bulky, resulting in dry neovaginal vaults of lesser dimensions.19Bizic M Ko
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