Technical Refinements of Vulvar Reconstruction in Gender-Affirming Surgery.

Abstract

Sir: We read with interest the recent publication by Dy et al. in which the authors shared their experience with the penile inversion technique of vulvar reconstruction.1 Although the authors presented some technical refinements in their report, they set the following goals, which could potentially be applicable for aesthetic evaluation of any vulvar reconstruction. Well-defined and three-dimensional labia minora surrounded by prominent labia majora were the base of their aesthetic description. The labia minora framing the patent introitus that appears closed at rest and a “sufficient clitoral hooding” were some additional aesthetic goals described by Dy et al.1 While we agree with the above-mentioned aesthetic goals, we would like to add appropriate size of the neoclitoris, position and three-dimensional relationship of the neoclitoris in relation to the clitoral hood (ideally, the neoclitoris should not be very small and fully hidden; nor is it supposed to be very large or prominent; and it is not covered by the hood) as additional potential aesthetic goals worth mentioning.2 We agree with Dy et al. that there are not many detailed publications currently present in the medical literature that describe or compare the aesthetic details between different techniques of vulvar reconstruction in gender-affirming surgery. While comparing aesthetic outcomes of different techniques, some additional important factors that determine the success of surgery include the clitoris sensation, its future role in arousal and sexual function, undesired erection of the corporal stump, and vaginal depth; also, the complication rates should not be overlooked.2–5 We would like to get some further information from the authors as to whether any of the above-mentioned data are available in their patients’ population and can be shared with us. Dy et al. appropriately brought up the principles of replacing like tissues with like, considering aesthetic subunits when reconstructing the vulva (particularly the clitoral hood and labia minora), “mirroring homologous structures in natal vulva,” and attempting to place incisions and suture lines along topographic subunit borders. These efforts are completed when the surgeons ensure that sexual sensation or vaginal depth are not compromised. Although Dy et al. simply pulled the new labia majora and minora and anchored them together to the perineum to create posterior commissure and fourchette,1 Pariser and Kim suggested using posteriorly based triangular flaps at the perineal area to augment vaginal introitus and create a posterior fourchette, which could be a valuable addition to the former technique.2 Although up to 30 percent of women who undergo gender-affirming surgery may be circumcised, which has implications in labia minor and clitoris hood reconstruction,3 Dy et al. did not describe what changes should be made in circumcised versus noncircumcised patients with regard to their refined technique. The technique described by Dy et al. has provided aesthetically appealing and very natural appearing labia majora and minora, but has not addressed much satisfactory outcome on the neoclitoris complex and its aesthetic relationship with the clitoral hood even in the photographs provided. Watanyusakul4 used a complex reconstruction for the neoclitoris, clitoral hood, and clitoral frenulum, and Opsomer et al.3 described using a W-shaped neoclitoral flap. Both techniques could be additions to the technique described by Dy et al. In conclusion, we want to applaud the authors for providing a valuable addition to the currently published literature addressing the aesthetic aspect of penile inversion technique of vulvar reconstruction and would appreciate the authors’ further clarifications/comments on the above-mentioned issues. ACKNOWLEDGMENT The authors thank Talicia Tarver for editorial assistance. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Alireza Hamidian Jahromi, M.D.Petros Konofaos, M.D.Department of Plastic SurgeryUniversity of Tennessee Health Science CenterMemphis, Tenn.