Abstract: Clitoroplasty and Labia Minoraplasty in Penile Inversion Vaginoplasty in Circumcised and Uncircumcised Transwomen

Abstract

INTRODUCTION: Gender dysphoria, the incongruence between anatomic sex and gender identity is estimated to affect 1% of the population. Creation of a feminine vulva remains a technical challenge for surgeons, especially in circumcised patients. We present a vulvoplasty technique with creation of neoclitoris and labia minora using a dorsal glans pedicled flap with prepuce skin in uncircumcised patients or distal shaft skin in circumcised patients. METHODS: A retrospective case review was performed of all penile inversion vaginoplasties performed by senior author between 2014 and 2016. History of circumcision, use of full thickness skin grafts to lengthen vault, necrosis of labia minora, and any revisionary surgery was recorded. RESULTS: A total of 159 single stage penile inversion vaginoplasty operations were performed using the described technique from 2014–2016. All patients were evaluated by the UZ Gent multidisciplinary gender team prior to surgery and met standards of care established by WPATH. The majority, 97.5 % of patients, required FTSG to lengthen the vaginal vault. Creation of clitoral hood and labia minora was achieved in all patients with 3.2 % requiring minor aesthetic refinements for partial skin necrosis and 25.8% for labia majora refienments or dehiscence. Just one patient experienced total necrosis of the labia minora prepuce flap tissue. Average length of follow-up was 2 years. The neoclitoris is constructed from a M-shape dorsal glans flap, sutured into a dome, and inset to the distal resected corporal bodies in the anterior midline. The urethra mucosa is inset as a shield and the prepuce flap is wrapped laterally and posteriorly to construct labia minora. In circumcised patients, distal penile shaft skin is used in absence of prepuce skin and survives on random blood supply through the circumcision scar. Labia majora are fashioned from the scrotal skin. Remaining penile shaft skin is inverted to construct the introitus and vaginal apex is lined with full thickness skin graft from excess scrotal skin. Postoperative genital aesthetics were excellent. CONCLUSION: Creation of the clitoral hood and labia minora during penile inversion vaginoplasty is achievable in both circumcised and uncircumcised patients with excellent aesthetic results and low revisionary surgery rate.