• Anatomy
• Regions:
• Perineum: includes the area between the vagina and the anus in women and the area between the scrotum and the anus in men. Also described as the pelvic outlet- which is the are between the pubic symphysis and coccyx. 
• Contains two fascial layers superficial and deep –> deep layer is continuous with colles fascia of the thigh
• Male: Penis: consists of root, body, and epithelium (glans penis)
• Penile Layers: Skin, dartos fascia, Bucks Fascia, and tunica albuginea
• Neurovascular Bundle: deep dorsal vein, dorsal artery and paired dorsal nerves of the penis
• Erectile tissue: paired corpora cavernosa and corpora spongiosum; urethra passes through corpus spongiosum and the meatus, ends at the tip of the glans penis
• Scrotum:  
• Female: Vulva- includes mons pubis labia majoria, minora, clitoris, and vestibule
• Labia majora: skin, camper’s fascia, and colle’s fascia (continues with scarpa’s)
• Labia majora has inferior attachment on the ischiopubic rami that prevents the spred of hematomas and infections
• Labia minora: folds of skin without fat 
• Clitoris: derived from undifferentiated phallus and has paired corpora, vestibular bulbs and glans
• Vagina: muscular tubular structure that extends from the vulva to the uterus –> opening located posterior to the urethra and is closed by the labia minora
• Length (typically) 6cm across anterior wall and 7.5cm across posterior wall; width 2.6-3.25cm
• Arterial supply: 
• Internal pudendal artery (supplies perineum) from the internal iliac
• Perineal artery –> supplies perineum and scrotum/vulva
• Common penile artery: three branches (bulbourethral, dorsal, deep cavernosa)–> travels below Buck’s fascia and above the tunica albuginea (remember tunica albuginea envelops the corpus cavernosum)
• Superficial and deep external pudendal artery
• Branch off of the medial side of femoral artery
• Supplies skin of lower abdomen and anastomoses with the internal pudendal artery to supply the genitalia
• Testicular ovarian arteries: branch off aorta where gonads originate
• Uterine artery: supplies vagina
• Innervation:

• Pudendal nerve: (s2-4)–> follows course internal pudendal artery; perineal nerve (deep motor branch); dorsal nerve of penis/clitoris; posterior scrotal/labial nerves; inferior anal nerves
• Ilioinguinal nerve (L1): anterior scrotal/labial nerve –> root of penis/mons and upper part of scrotum/labium majora (innervate the anterior vulva)
• Congenital Defects
• Acquired
• Cancer, Trauma, Peyronie’s disease (correlates with dupuytren’s)
• Reconstruction considerations: high bacterial counts (second highest in body), avoiding wound contamination with stool and urine, pressure necrosis, high infection and dehiscence rates–> 66% dehiscence rate 
• Chemoradiation (inflammation/ulceration), fibrotic changes
• Poor nutritional status
• Goal of reconstruction: to return to sexual activity (50% actual return)
• Classification of Defect: (cordeiro et al)
• Partial Type I 
• Anterior or lateral wall (ia), posterior wall (ib)
• Circumferential II
• Upper 2/3 or total
• Treatment for vaginal defects: 
• Singapore:
• First described as 15x6cm skin flap with medial incision in the thigh crease lateral to the hair bearing area, posterior flap at the posterior fourchette
• Arterial supply is posterior labial arteries (branches of pudendal artery)
• Sensation via posterior labial branches of the pudendal nerve
• Elevated in fasciocutaneous plane of the deep fascia of the thigh, directly over adductor muscles –> transposed 70 degrees. Donor site primarily closed 
• Several variations
• Modified singapore flap
• Pudendal thigh flap or singapore flap based off of superficial perineal artery
• Superficial perineal nerve supplies sensation to flap for IMMEDIATE sensation post operatively
• Good for posterior vaginal reconstruction
• Used for Ia defects (unilateral or bilateral)
• Vertical rectus flap
• Most evidence for APR or LAR defects (large composite defects) s/p radiation
• Ib defects (posterior vaginal wall defects)
• Typically after colorectal cancer extending into the vaginal septum and can include vaginal wall and pelvic contents
• Brings healthy tissue into area without radiation
• Mathis and Nahai III; blood supply superior and deep inferior epigastric (based on deep inferior epigastric)
• Skin paddle designed paramedian, primary abdominal wall closure
• Iia (circumferential upper 2/3) may be reconstructed with rolled VRAM, usually after cervical or other gynecologic malignancies–> flap width usually 12-15cm
• Bilateral gracilis flap
• Good for total vaginal reconstruction with or without skin paddle
• Inconsistent sensation; reliable perforator
• Unilateral or bilateral
• Iib circumferential total defects use bilateral myocutaneous flaps (typically after total pelvic exonerations)
• Arterial supply medial femoral circumflex artery with secondary minor pedicles derived from the superficial femoral artery in a segmental fashion
• Identification: line drawn from pubic tubercle and semitendinous tendon (denotes anterior border of gracilis) –> pedicle will enter 7-10cm  below the pubic tubercle in space between adductor longus and magnus

• Skin island may be as large as 6-20cm along the proximal 2/3 of muscle; make sure to design over adductor to include all of the perforators
• Vulvar reconstruction: typically from SCC or other types of skin cancer; lichen sclerosis, HPV
• Divided into upper third (mons and labia), middle third (labia proper), lower third (vaginal orifice and perineum)
• Upper third defects may be closed primarily, larger defects with pedicled ALT
• Pedicled ALT
• For large upper third vulvar defects, based on descending branch of the lateral circumflex artery (between vastus lateralis and medialis)
• Perforators found at midpoint between ASIS and patella, 5cm inferior and superior
• Dissection occurs with anterior incision first, the flap then transferred in subcutaneous plane
• May tunnel under rectus and sartorius to add pedicle length; muscle may be added if dead space is present
• Middle third defects:
• Singapore flap, gracilis, gluteal fold flaps
• Gracilis most typically used (great for cases with radiation)
• Lotus flap: modification of singapore flap uses superficial perineal artery perforators, design of lotus
• Lower third defects: (vaginal orifice or perianal)
• Gluteal fold flap: marked preoperatively with patient in standing position
• Flap located in triangle formed by ischial tuberosity, anus, and vaginal orifice or scrotum
• Skin flap elevated under fascia of gluteus maximus
• Based on internal pudendal perforators, may include posterior cutaneous nerve of the thigh if sensory component desired
• Treatment for Penile defects/reconstruction: typically after resection of lichen sclerosis, carcinoma of penis, neuroendocrine tumors
• Classified as partial or complete
• Radial forearm flap: gold standard for total penile phalloplasty and gender reaffirming surgery
• Innervated skin island- antebrachial cutaneous–> co-apted to the pudendal nerves or dorsal nerve to the penis
• Forearm skin for neourethra from a central urethral strip, is tubed over a 12-14 F silicone urinary catheter
• Free sensate osteocutaneous fibula flap
• Main advantage to fibula flap over RFFF is avoidance of prosthesis to provide erectile and sexual function
• Less conspicuous donor site
• Innervated skin island- via peroneal nerve
• Will need FTSG for neourethra- more likely to have urethral constriction
• Pedicled ALT
• Tube in tube technique with preservation of the lateral femoral cutaneous nerves
• Neophallus constructed while flap in thigh
• Scrotal Reconstruction: a quick word; in absence of prior radiation therapy, STSG typically used
• Superomedial thigh flaps with pouch
• Pedicled ALT
• Gracilis
• Tissue expansion
• Examples:
• Traumatic Amputation of Penis: attempt microvascular replantation –> keep on saline soaked gauze, place in sterile bag, place bag in slush –> order urinary diversion with suprapubic catheter, urethral anastomosis over foley, corporal body coaptation by approximating tunica albuginea, microsurgical anastomosis of dorsal vessels, nerves, skin closure
• Internal iliac –> internal pudendal artery –> deep dorsal penile arteries
• Fournier’s Gangrene
• Transgender: 1.4 million people currently identify as transgender
• Gender dysphoria: defined by DSM-5 as a person whose gender at birth is incongruent with their gender identity
• Preoperative assessment 
• WPATH (world professional association for transgender health)
• ALL patients must have capacity for informed consent
• Age of consent is 18 years; F-M breast surgery can undergo if they have a consenting guardian, have lived in congruent identify for at least 1 year and have completed 1 year of testosterone therapy
• ALL patients must have a referral from a mental health professional that documents persistent gender dysphoria
• 1 referral required for chest reconstruction
• 2 referrals for patients seeking genital reconstruction
• Co-morbidities should be managed
• Hormone therapy not required for chest affirmation but is encouraged (12 months for male to female for aesthetic outcomes)
• Hormone therapy required for 12 months prior to any genital reconstruction surgery
• Patients must have lived for 12 months continuously in their gender role  

WPATH Requirements	Chest/Breast	Genital	Facial or other Gender affirmation surgery
Documented Referral of Gender Dysphoria from Mental Health Provider	1 referral	2 referrals	Not required
Capacity of informed Consent	Required	Required	Required
Age of Consent	>18*	>18 only	>18 or guardian consent
Hormone therapy	Not Required	Required 12 Continuous Months	Not Required
Living in Congruence with Gender Identity	Not Required	Required 12 Continuous Months	Not Required

• Male to Female: largest portion of the transgender population

• Chest: Implant based breast aug most common MTF chest surgery
• Hormone therapy not required, estrogen recommended prior to surgery to allow for breast growth and improved results
• Fat grafting can be utilized
• Approach to operative management similar to cis patients
• Anatomy: male chest slightly wider

• Preference for incision and plane placement surgeon dependent
• Complications are similar (capsular contracture, hematoma, prosthesis rupture)
• Breast mammography screening every 2 years starting at 50 or 5-10 years after feminizing hormone
• Genital Reconstruction: goals are sexual sensation, functional vagina, acceptable cosmesis
• Penile inversion vaginoplasty is gold standard –> includes scrotal excision, high end ligation orchiectomy, dissection of the penis, creation of a neovagina in the pre-rectal space, creating neoclitoris utilizing the glans penis and neourethra anastomosis
• Neovaginal stenosis most common complication
• Patients may experience meatal stenosis or splayed urinary stream
• Need to undergo prostate screening even after surgery
• Female-to-Male Surgery:

• Chest: subcutaneous mastectomy performed for those that desire chest contour

• Goals include male contour, acceptable positioning of NAC and minimal scars
• Breast size and skin elasticity are most important factors when planning surgical incisions
• Small breasts or grade I ptosis: liposuction may be performed or transaereolar approach
• Medium breasts with moderate ptosis concentric or extended concentric design
• Large breasts or Grade III ptosis: mastectomy and free nipple graft best option
• Post chest reconstruction should continue cisgender female screening for breast cancer if no mastectomy or breast reduction performed\
• Genital: goals of reconstruction is to create an ideal neophallus that is aesthetically pleasing, has intact tactile and erogenous sensation, provides standing urination, imparts minimal donor site morbidity
• Metoidoplasty: involves creation of a neophallus from hypertrophied clitoris 
• Clitoris is dissected with detachment of clitoral ligament and division of the urethral plate with urethroplasty to increase neophallus length
• Drawback is shorter neophallus (5-7cm)
• Pedicled phalloplasty with ALT: can be used for a “tube within a tube” flap design for neourethral formation
• Reliable vascular supply, discrete donor site
• Difficulties include thick subq layer that limits tube formation and need for prosthesis for erectile function
• Phalloplasty with RFFF: aesthetic neophallus with adequate length for standing urination
• Neurorrhaphy is antebrachial cutaneous and dorsal clitoral or ilioinguinal nerves (sensate)
• Donor site morbidity downside
• Urologic dysfunction including urethral strictures and fistulae are most common
• Most patients undergo TAHBSO prior to phalloplasty, still need cervical cancer screening after genital recon

FtM Genital Reconstruction	Length	Standing Urination	Sensation	Donor Morbidity
Metoidoplasty	Poor	Difficult	Great	Minimal
Pedicled ALT Phalloplasty	Good	Yes	Poor	Minimal
RFFF Phalloplasty	Excellent	Excellent	Great	Significant

References

• Coleman, E., et al. “The standards of care of the world professional association for transgender health, 7th version.” Int J Transgenderism 13 (2011): 165-232.
• James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. A. (2016). The report of the 2015 US transgender survey. Washington, DC: National Center for Transgender Equality.
• Weyers, S. et al. 2009. Long-term assessment of the physical, mental, and sexual health among transsexual women. The journal of sexual medicine. 6, 3 (Mar. 2009), 752–60.
• Claes, K. et al. 2018. Chest Surgery for Transgender and Gender Nonconforming Individuals.
• Monstrey, S. et al. 2008. Chest-wall contouring surgery in female-to-male transsexuals: a new algorithm. Plastic and reconstructive surgery. 121, 3 (Mar. 2008), 849–59.
• Buncamper, M. et al. 2016. Surgical Outcome after Penile Inversion Vaginoplasty. Plastic and Reconstructive Surgery. 138, 5 (2016), 999–1007.
• Morrison, S.D. et al. 2016. Phalloplasty: A Review of Techniques and Outcomes. Plastic and reconstructive surgery. 138, 3 (Sep. 2016), 594–615.
• Frey, J.D. et al. 2017. An Update on Genital Reconstruction Options for the Female-to-Male Transgender Patient: A Review of the Literature. Plastic and reconstructive surgery. 139, 3 (Mar. 2017), 728–737
• Massie, J.P. et al. 2018. Predictors of Patient Satisfaction and Postoperative Complications in Penile Inversion Vaginoplasty. Plastic and reconstructive surgery. 141, 6 (Jun. 2018), 911e–921e.