Transsexual Patients Research Articles

One-step facial feminization surgery: The importance of a custom-made preoperative planning and patient satisfaction assessment

BackgroundThe availability of more accurate techniques used for transgender surgery has resulted in an increased number of patients requesting facial feminization surgery (FFS). The aim of this study was to present the FFS pre-operative planning of the authors’ male-to-female transsexual patients using photo-editing software, computer-aided design (CAD), modeling, and three-dimensional (3D) printing. Material and MethodsTwenty-five patients underwent FFS between November 2015 and May 2018. They were retrospectively included in this study, and their records were analyzed. Patients’ 3D facial models were printed and used for an accurate preoperative planning and shown to the patients. To assess patient satisfaction, the preoperative, six-month, and one-year postoperative scores obtained using Satisfaction With Life Scale (SWLS) and Subjective Happiness Scale (SHS) were compared. The scores following a normal distribution obtained for each patient were compared using a paired t-test. ResultsThe 3D model preparation mean time was 145±13.2 min. A total of 114 surgical procedures were carried out. The mean operative time was 420±23 min. Patients experienced no postoperative complication. All patients were very satisfied after surgery, with a significant difference between pre- and postoperative scores (p = 0.002; p = 0.03). ConclusionWith use of 3D modeling, surgeons are nearing a custom-made surgery era, especially required for complex procedures such as FFS. We suggest using 3D technology for a more accurate preoperative planning.

Nipple-Areolar Complex Position in Female-to-Male Transsexuals After Non-skin-excisional Mastectomy: A Case-Control Study in Japan.

Mastectomy is performed in female-to-male transsexual (FTM TS) patients as a surgical treatment to make a female thorax resemble a male thorax; however, no studies have examined the nipple-areolar complex (NAC) position in FTM TS patients after mastectomy. The NAC position in 41 FTM TS patients before and after non-skin-excisional mastectomy was examined and compared with that in 50 age- and BMI-matched biologically male subjects as controls. The factors affecting the NAC position after the operation were also examined and verified by multiple regression analysis. After non-skin-excisional mastectomy, the NAC in the FTM TS patients was positioned significantly more medially (horizontal NAC position ratio {('internipple distance'/'width of thorax') × 100} [HNPR]: preoperatively, 70.07% ± 4.19%; postoperatively, 63.28% ± 3.79%) and cranially (vertical NAC position ratio {('distance from sternal notch to nipple height'/'distance from sternal notch to umbilicus') × 100} [VNPR]: preoperatively, 43.87% ± 3.68%; postoperatively, 41.37% ± 3.15%). Postoperatively, the NAC in the FTM TS patients was located significantly more medially than that in the control subjects (HNPR: 63.28% ± 3.79% to 66.79% ± 4.82%), although the height of the NAC was the same. Multiple regression analysis revealed that the NAC position on breasts characterized by ptosis, a high projection, and lateral leaning (low skin elasticity and a substantial amount of skin between the nipples) tended to be positioned more medially after non-skin-excisional mastectomy. Laterally deviated eccentric circulartype mastectomy may be a good option for FTM TS patients who have moderately sized breasts with such features. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

State of mind of attachment and reflective function in an Italian transsexual sample

IntroductionAccording to the DSM-5 (APA, 2013), gender dysphoria is a form of incongruence between the subjective experience of belonging to a specific gender and the gender one has been assigned at birth. ObjectiveThe purpose of this paper is to explore attachment state of mind in a transsexual adult population in order to identify the most appropriate ways and forms of interventions, since improving attachment state of mind might boost the subject's quality of life. MethodThe sample consisted of 52 transsexual patients, of whom 51.9% were biologically male (MtF; n=27) and 48.1% female (FtM; n=25). ResultsThe data obtained through the Adult Attachment Interview (AAI, George et al., 1985) show that the majority of the participants (92.3%) were found to have an insecure attachment state of mind. When classifying participants with GD on the basis of one of three attachment state of mind, 71.2% (n=37) of the sample showed a dismissing state of mind with respect to attachment and 21.2% (n=11) an entangled state of mind. The data obtained through the AAI also show that almost half of the sample reported one or more traumatic life events, with no differences found between the MtF and FtM groups. Using the Unresolved/disorganized (U/d) condition to classify the AAI data, we found frequent signs of unresolved experiences of trauma among those with an insecure attachment state of mind. No traumatic experiences with respect to attachment were reported by participants who were classified as secure. ConclusionOur findings suggest that interventions with transgender patients should impact on their current state of mind relating to attachment and traumatic experiences by promoting a secure state of mind with respect to attachment.

Laparoscopic sacrocolpopexy for neovaginal prolapse in a patient after male-to-female sex reassignment surgery.

ABSTRACTIntroduction:Male / female sex reassignment surgery is performed on transsexuals, and includes removal of the male external genitalia, and creation of the neovagina from the skin of the penis, usually allowing sexual intercourse (1, 2). The incidence of the prolapse of the neovagina is not known; however, such complication is observed relatively rarely (3, 4). the long-term outcomes of prolapse treatment in transsexual patients are not available in the literature. The purpose of this study was to demonstrate laparoscopic sacrocolpopexy to repair a neovagina prolapse in a patient after male-to-female sex reassignment surgery.Materials and Methods:In september 2013, a laparoscopic repair was performed on a 44-year-old woman who presented a neovaginal prolapse of pelvic organ prolapse quantification (pop-q) stage iii, twenty one years after sex reassignment surgery. This condition caused painful or even indisposed intercourse. in may 2013, the patient underwent unsuccessful vaginal treatment with the suturing device. Before the initial surgery, the patient was examined with cystoscopy, urodynamics and microbiology; no pathologies were found. laparoscopic repair of the neovaginal prolapse followed the principles described previously in the natural female (5). In the supine lithotomy position, a standard multiport laparoscopic sacrocolpopexy was performed with the use of the polypropylene mesh (Artisyn® y-shaped mesh, ethicon, inc somerville, nj.) and coated polyglactin sutures.The following steps were applied:exposure of the anterior and posterior neovaginal walls; suturing the bifurcated end of the mesh to the neovagina; longitudinal incision of the parietal peritoneum and creation of a tunnel for the mesh; fixation of the proximal end of the mesh to the promontorium; and closure of the parietal peritoneum over the mesh that was placed retroperitoneally. The draining tube was left for 24 hours.Results:The operation was completed successfully, with no blood loss or complications. The operative time was 115 minutes. The patient was discharged on the 2nd postoperative day. In a four-year follow-up, the patient presented significant improvement of symptoms, a small prolapse of approximate pop-q stage i, and declared performing satisfying intercourse.Conclusions:Laparoscopic sacrocolpopexy with the use of a polypropylene mesh to repair a neovaginal prolapse in transsexuals seems to be a valuable alternative to other procedures. Further observations and evaluation of a greater number of patients will be necessary to assess the actual value of the method.

Transgender Care Knowledge and Attitudes Amongst Puerto Rico's Gynecologists [18P

INTRODUCTION: Transgender refers to individuals whose gender identity and/or expression of gender differs from gender assigned at birth. Countless roadblocks prevent access to medical services due to stigmas and prejudices, lack of knowledge and experience in terms of their healthcare needs, and insensitive treatment from their providers. Even though the gynecology field is involved in care of transgender individuals, there is scarce literature and guidelines focused on their care. The aim of this study is to learn about attitudes, disposition and knowledge of transgender medical care amongst gynecologists actively practicing in Puerto Rico (PR). METHODS: After Institutional Review Board approval, gynecologists were invited to complete a survey designed to determine knowledge about transgender care, disposition, and experience treating transgender patients. The administered questionnaire was previously used in a study evaluating gynecologists from the continental United States but had yet to be done in PR. Responses were catalogued using Epi Info frequency analysis. RESULTS: Fifty-nine participants were recruited. When asked if comfortable taking care of male-to-female transsexuals (MTFT), 59% agreed. In female-to-male transsexuals (FTMT), 47% agreed. Regarding if would perform pap smears on FTMT 81% agreed, whereas 80% felt comfortable performing breast exams on MTFT. Of the respondents 49% are not familiar with hormonal regimens used for gender reassignments. 70% of respondents knew there is a Practice Bulletin on the care of the transgender patient. CONCLUSION: There is a willingness to treat transsexual patients amidst PR gynecologists but the lack of knowledge regarding population specific treatments and managements represents a limitation.

PO-01-082 Gender Reassignment Surgery: Preliminary outcomes of the Trakya University Health Center for Medical Research and Practice

To report the first outcomes on transsexual patients in Turkey, undergoing gender reassignment surgery (GRS), by the collaboration of plastic and urologic surgeons, of a single center. The data of patients diagnosed with gender identitiy disorders, between January 2015 (start of surgery) and November 2018, who underwent female to male (FtM) and/or male to female (MtF) GRS were retrospectively analyzed. Patients were excluded if they were pseudohermaphrodites, reluctant for GRS and if their gender was not reported. A total of 58 patients referred for GRS were included. One patient was diagnosed with pseudohermaphroditism, two patients gender was not reported and eight patients were unwilled for GRS. Apart from those, 27 cases (57%) were MtF and 20 cases (43%) were FtM. For MtF cases, 27 underwent vaginoplasty, 26 of whom received breast augmentation. Top surgery (mastectomy) and phalloplasty was performed in all FtM patients, in which 10 patients received an urethral lengthening to the tip of the phallus. However, penile prothesis implantation, in none of these patients has been performed, currently. Minor complications occured in seven MtF patients like labial and/or pubic insicional scars (6 patients) and meatal stenosis (one patient), which were succesfully treated afterwhiles. Despite that, in FtM patients with urethral lengthening, complications like urethral fistula (two patients) and urethral/meatal stenosis (five patients) with more severe outcomes consisted.

Socio-demographic portrait of transsexual patients in Russia

Transsexualism is a distress caused by a discrepancy between a person’s gender identity and sex assigned at birth. Theme of transsexualism has a strong resonance in society today. This phenomenon is significant both for the law system and for the health care system of the state. There is no statistics information on transgender people in Russian Federation. The author’s goal was to draw a socio-demographic portrait of patients with an established diagnosis of transsexualism. The following conclusions were made: the number of MtF and FtM patients searching for medical care is equal; age of the transition is 26.6 years; age of selfidentification in the opposite gender is 10.2 years; most MtF take HRT on their own initative; transsexual persons are distinguished by a high level of education, large variety of professional activities, a low percentage of registered marriages, and comparable to the general population onset of sexual life.

Histerectomía por laparoscopia en un transexual masculino: reporte de caso y revisión de la literatura

Objetivo: reportar un caso de histerectomía por laparoscopia convencional en cambio de sexo female-to-male en Colombia, en un paciente diagnosticado como transexual, y realizar una revisión de la literatura respecto a las distintas alternativas de histerectomía en el contexto de esta condición.Materiales y métodos: paciente de 35 años, transexual, en tratamiento hormonal con undecanoato de testosterona, sometido a histerectomía laparoscópica como parte de reasignación de sexo, en una institución de III nivel de complejidad, con evolución posoperatoria favorable. Se realizó búsqueda en las bases de datos de Medline vía PubMed, Embase y Lilacs, con los términos MESH: “hysterectomy”, “laparoscopy”, “transsexualism”, en inglés, español y checo, sin limitación de tiempo.Resultados: la investigación incluyó 11 estudios: 3 estudios de serie de casos, 6 cohortes, 1 ensayo clínico controlado y 1 reporte de caso. La histerectomía laparoscópica es la más utilizada para la reasignación de sexo en transexuales masculinos. La histerectomía vaginal es una alternativa por considerar si se requiere musculatura abdominal para futura faloplastia.Conclusiones: la histerectomía por laparoscopia surge como una alternativa a la histerectomía vaginal en pacientes transexuales masculinos sometidos a cirugía de reasignación de sexo. Se requieren ensayos controlados aleatorizados para una mejor evaluación comparativa de las alternativas quirúrgicas disponibles.

Aesthetic Refinement in the Creation of the Clitoris, Its Preputial Hood, and Labia Minora in Male-to-Female Transsexual Patients.

In male-to-female genital sex reassignment surgery, the clitoris, its prepuce, and the labia minora remain among the most difficult structures to construct. We describe the authors' clitoroplasty and vulvoplasty technique. All patients who underwent male-to-female sex reassignment surgery at a single center, between June 2012 and June 2016, were prospectively included. The standard pedicled island neurovascular flap of the glans penis was harvested in a letter M fashion with attached preputial skin. The central triangle of the M was used for the neoclitoris formation. Labia minora and the clitoral prepuce were created with both legs of the M and the preputial skin attached to it. Tactile and erogenous sensitivity was evaluated. Ninety-seven patients were included (mean age, 32 years; range, 17-54 years). All clitoroplasties and vulvoplasties were completed in the same surgical stage as the vaginoplasty. There were no cases of deep or total flap necrosis. Eight patients developed partial and superficial skin necrosis of the flap; one presented an abscess in labia majora, and another patient had urethral hematoma; both required drainage. None of the complications left any sequelae. At 6 months' follow-up all patients maintained tactile and erogenous sensitivity. The proposed technique represents an aesthetic refinement of the previously described pedicled glans penis flap by allowing the creation of a sensate neoclitoris, its preputial hood, and labia minora with excellent outcomes in the same surgical stage as the sex reassignment.

Élaboration d’un questionnaire de satisfaction encadrant la chirurgie de féminisation faciale chez les patientes transsexuelles male to female (QESFF1) : Phase qualitative

Facial feminization surgery is becoming a more frequently requested procedure in transsexual male to female patients transformation. A global way of reporting outcomes data and showing the beneficial impact of this specific procedure is necessary. The objective of this study is to develop a reliable and valid tool to report patients' outcomes after facial feminization surgery. A systematic literature review, input from experts working with transsexual patients and patient interviews were used to develop the conceptual framework of the questionnaire. It includes the outcomes deemed important to facial feminization surgery and it was used to construct items of the questionnaire. There is no specific tool for measuring patients outcomes after facial feminization surgery. Ten experts and 18 patients participated to this study. The conceptual framework includes the following themes: satisfaction with facial feminine appearance; adverse effects; quality of life. The questionnaire includes fourteen separate Likert scales, with preoperative and postoperative versions. The reliability of the questionnaire is excellent with a medium Alpha score of 0.85. Facial feminization surgery is associated with high patient satisfaction in this sample (83.7±7.41). QESFF1 is a reliable questionnaire and its development follows the steps recommended by the patient-reported outcomes process. A large sample pilot test is needed to demonstrate its validity. The QESFF1 can provide physicians with the necessary tools to measure the impact of facial feminization surgery on male to female transsexual patients and also has the potential to support clinical trials.

Abstract 11.05 THE MICROVASCULAR “TUBE- IN- TUBE” CONCEPT FOR PENILE CONSTRUCTION IN FEMALE TO MALE TRANSSEXUALS

INTRODUCTION: In most female-to-male transsexual patients the construction of an aesthetic and functional neo-phallus after penile amputation represents the terminal step in a series of invasive and non-invasive procedures. For this surgery, a lot of different techniques have been described. Among these microsurgical free-flap phalloplasties remain the most popular method in clinical routine. For many years, the radial forearm free flap has been considered to be the best procedure. With the aim to reduce donor site morbidity and to optimize functional outcome many other flaps have been developed. Therefore, pedicled flaps have shown to be reliable and to decrease the risk of total failure. RESULTS: We describe a new “tube- in tube” technique combining either a pedicled SCIP (Superficial circumflex iliac artery perforator) flap or a free RFF (radial forearm) flap with an ALT (Anterolateral thigh flap) free flap. By using the SCIP/ radialis flap as part mobile of the Urethra the inner tube is formed. The ALT flap builds the outer tube. By presenting cases of this technique, first experiences, outcome and the most occurring complications should be showed. CONCLUSION: By combining the reliability of pedicled flaps with the benefits in aesthetic outcome of free flaps, this new “tube- in- tube” technique represents a method to reduce complete flap failure by simultaneously decrease complication rate.

Sexuality after Male-to-Female Gender Affirmation Surgery.

Male-to-Female (MtF) gender affirmation surgery (GAS) comprises the creation of a functional and aesthetic perineogenital complex. This study aimed to evaluate the effect of GAS on sexuality. We retrospectively surveyed all 254 MtF transsexual patients who had undergone GAS with penile inversion vaginoplasty at the Department of Urology, University Hospital Essen, Germany, between 2004 and 2010. In total, we received 119 completed questionnaires after a median of 5.05 years since surgery. Of the study participants, 33.7% reported a heterosexual, 37.6% a lesbian, and 22.8% a bisexual orientation related to the self-perceived gender. Of those who had sexual intercourse, 55.8% rated their orgasms to be more intensive than before, with 20.8% who felt no difference. Most patients were satisfied with the sensitivity of the neoclitoris (73.9%) and with the depth of the neovaginal canal (67.1%). The self-estimated pleasure of sexual activity correlated significantly with neoclitoral sensitivity but not with neovaginal depth. There was a significant correlation between the ease with which patients were able to become sexually aroused and their ability to achieve orgasms. In conclusion, orgasms after surgery were experienced more intensely than before in the majority of women in our cohort and neoclitoral sensitivity seems to contribute to enjoyment of sexual activity to a greater extent than neovaginal depth.

Fronto-orbital feminization technique. A surgical strategy using fronto-orbital burring with or without eggshell technique to optimize the risk/benefit ratio

The demand for facial feminization is increasing in transsexual patients. Masculine foreheads present extensive supraorbital bossing with a more acute glabellar angle, whereas female foreheads show softer features. The aim of this article is to describe our surgical technique for fronto-orbital feminization. The mask-lift technique is an upper face-lift. It provides rejuvenation by correcting collapsed features, and fronto-orbital feminization through burring of orbital rims and lateral canthopexies. Depending on the size of the frontal sinus and the thickness of its anterior wall, frontal remodeling is achieved using simple burring or by means of the eggshell technique. Orbital remodeling comprises a superolateral orbital opening, a reduction of ridges and a trough at the lateral orbital rim to support the lateral canthopexy. Frontal, corrugator and procerus myectomies, plus minimal scalp excision, complete the surgery. Our technique results in significant, natural-looking feminization. No complications were observed in our series of patients. The eggshell technique is an alternative to bone flap on over-pneumatized sinus. Fronto-orbital feminization fits into a wider surgical strategy. It can be associated to rhinoplasty, genioplasty, mandibular angle remodeling, face lift and laryngoplasty. Achieving facial feminization in 2 or 3 stages improves psychological and physiological tolerance.

Ethical Issues in The Treatment of Transsexual Patients

Ethical Issues in The Treatment of Transsexual Patients

Autologous Fibroblast-Seeded Amnion for Reconstruction of Neo-vagina in Male-to-Female Reassignment Surgery.

Plastic surgeons have used several methods for the construction of neo-vaginas, including the utilization of penile skin, free skin grafts, small bowel or recto-sigmoid grafts, an amnion graft, and cultured cells. The aim of this study is to compare the results of amnion grafts with amnion seeded with autograft fibroblasts. Over 8years, we compared the results of 24 male-to-female transsexual patients retrospectively based on their complications and levels of satisfaction. Sixteen patients in group A received amnion grafts with fibroblasts, and the patients in group B received only amnion grafts without any additional cellular lining. The depths, sizes, secretions, and sensations of the vaginas were evaluated. The patients were monitored for any complications, including over-secretion, stenosis, stricture, fistula formation, infection, and bleeding. The mean age of group A was 28±4years and group B was 32±3years. Patients were followed up from 30 months to 8 years, (mean 36±4) after surgery. The depth of the vaginas for group A was 14-16 and 13-16cm for group B. There was no stenosis in neither group. The diameter of the vaginal opening was 34-38mm in group A and 33-38cm in group B. We only had two cases of stricture in the neo-vagina in group B, but no stricture was recorded for group A. All of the patients had good and acceptable sensation in the neo-vagina. Seventy-five percent of patients had sexual experience and of those, 93.7% in group A and 87.5% in group B expressed satisfaction. The creation of a neo-vaginal canal and its lining with allograft amnion and seeded autologous fibroblasts is an effective method for imitating a normal vagina. The size of neo-vagina, secretion, sensation, and orgasm was good and proper. More than 93.7% of patients had satisfaction with sexual intercourse. Amnion seeded with fibroblasts extracted from the patient's own cells will result in a vagina with the proper size and moisture that can eliminate the need for long-term dilatation. The constructed vagina has a two-layer structure and is much more resistant to trauma and laceration. No cases of stenosis or stricture were recorded. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Longitudinal course of eating disorders after transsexual treatment: a report of two cases

BackgroundSeveral reports have been published on patients with gender dysphoria and eating disorders. However, there have been few reports on the longitudinal course of eating disorders after gender reassignment surgery (GRS)/gender confirmation surgery (GCS).Case presentationWe report two Japanese cases of transsexual persons with eating disorders who underwent GRS/GCS, one male-to-female (MtF) and one female-to-male (FtM). Case 1 was a 35-year MtF person who had a 14-year-course of bulimia nervosa that developed after GRS. Case 2 was a 35-year FtM person with anorexia nervosa who underwent GCS 9 years before.ConclusionsWe found that the treatment of our transsexual patients influenced the course of their eating disorders for a long period, which could be attributable partly to the cultural situation in Japan, an East Asian country. It is possible that many gender identity problems and identity problems in general persist even after surgery and treatment; therefore, continual clinical support should be provided for patients with gender dysphoria and eating disorders even after hormonal therapy or GRS/GCS.

Autologous Buccal Micro-Mucosa Free Graft combined with Posterior Scrotal Flap Transfer for Vaginoplasty in Male-To-Female Transsexuals: A Pilot Study

The inverted peno-scrotal flap method is considered the standard method of vaginoplasty in male-to-female genital reassignment surgery. Though with numerous advantages, the method has its limitations regarding skin texture, lack of inherent lubrication, and that the tissues for creating the labia depend on the amount of tissues remaining after vaginoplasty. Our purpose was to describe the procedure and outcome of vaginoplasty applying a new technique: autologous buccal micro-mucosa free graft combined with posterior scrotal flap transfer, which could solve some of the problems the previous methods had. Nine male-to-female transsexual patients received our new method of vaginoplasty from July 2010-October 2015. We described the details of the surgical procedure and evaluated the long-term anatomical and functional outcomes. In a mean clinical follow-up period of 25.3months and phone interview follow-up of 50.3months, we observed that the neovaginas in the nine cases were all of sufficient volume, lined with mucosa, with natural mucosal discharge. The oral donor sites resulted in no visible scars or malfunction. Eight patients experienced uneventful postoperative periods, while one patient suffered from scrotal flap prolapse. All the patients were sexually active and reported sexual satisfaction, with no need of lubrication. The reported technique achieves the outcomes of creating a neovagina of sufficient volume, without serious stenosis in long-term follow-up. The neovagina is lined with mucosa and has appropriate lubrication as well as good sexual sensation. The reported method is easy and economical to perform and retains enough tissues for vulvoplasty to achieve a superior cosmetic appearance, with rare risk of complications and donor area malfunction. Additionally, this technique is feasible and advantageous to the patients who have insufficient peno-scrotal skin for neovaginal lining as well as those with unfavorable previous vaginoplasty. All of these indicate that this technique is a promising option for vaginoplasty in male-to-female transsexual surgery. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Role of Rhinoplasty in Transsexual Patients.

Role of Rhinoplasty in Transsexual Patients.

Phalloplastie : options microchirurgicales et algorithme décisionnel

The free radial forearm flap is considered as the gold standard in penile reconstruction for good functional and aesthetic results. The scar on donor site could be considered as pathognomonic of their situation by transsexual patients. The development of microsurgical flaps provides new therapeutic options. This options are discussed and a therapeutic algorithm is presented. The main techniques used are the pedicled anterolateral thigh perforator flap and free muscle sparing latissimus dorsi flap. Principal criteria are listed, the choice of patient and the local anatomical conditions are the most important. Antebrachial flap stay the first choice. In case of non-feasibility of this flap, phalloplasty with pedicle ALT flap or free MSLD flap will be proposed. Urethral reconstruction will be done by a narrow free forearm flap or by a delayed thin skin graft or buccal mucosa graft. Microsurgical phalloplasty options are not limited to the forearm flap. Satisfactory results can be obtained using alternative procedure. The use of a therapeutic algorithm allows to choose the most optimal solution for each patient.

First Female-to-Male Facial Confirmation Surgery with Description of a New Procedure for Masculinization of the Thyroid Cartilage (Adam's Apple).

Therapeutic, V.