XVII Harry Benjamin International Gender Dysphoria Association Symposium
31 October - 4 November 2001, Galveston, Texas, U.S.A.

The Standards of Microsurgical One Step Reassignment Surgery in Female to Male Transsexuals

DAVERIO, PAUL Switzerland
Co-author: Mishal Brugger (Switzerland)

The development of our microsurgical technique in the latest refinements in proximal ureteroplasty allows us to present the standards of the microsurgical one step reassignment surgery in female to male transsexuals. In 15 years we operated on 195 patients divided in 125 full one step operations, 52 pre-operated by mastectomy or/and hysterectomy and 18 secondary phalloplasty (abdominal wall phalloplasty and peroneal free flap phalloplasty). This operation is a team work: one plastic microsurgeon, one general plastic surgeon and one gynecologist.

Team 1 starts with the proximal ureteroplasty (prolongation of the female meatus). The new urethra remains attached to the corpus of the clitoris allowing the best vascularization of the flap. The clitoris remains in place de-epithelized, hidden under the scrotal skin, later acting as a trigger zone for the erogenous senses and orgasms. Once the ureteroplasty is done, follows the total colpectomy. The skin of the vagina is prepared over the cervix of the uterus. This manoeuver allows the gynecologist to practice a total hysterectomy, ovariectomy, annexectomy with the vagina in one piece. An inguinal transpubic incision is practiced that allows the preparation of the ilio-inguinal nerve on both sides. The abdominal flap is lifted. This first step of the operation lasts about 120 minutes. Simultaneously Team 2 performs the bilateral subcutaneous mastectomy. The skin is preserved for the covering of the forearm defect as a full thickness skin graft. If not, the skin has to be harvested from the inguinal region. this step lasts 90 minutes. Team 3, assisted by Team 2, performs a vertical laparotomy to practice a hysterectomy, annexectomy, ovariectomy and upper colpectomy (90 minutes). Meanwhile, Team 1 starts to prepare the forearm flap with a special design for a phalloplasty. The ulnar strip gives the penile urethra and the radial strip the shift of the neo-penis. The forearm flap is a radial free flap. The venous drainage is assured by the basilic and cephalic veins. The innervation is based on the musculocutaneous, lateralis and medialis nerves. This step is done under tourniquet and last between 75 and 105 minutes, depending on anatomical particularities. Team 1 closes the veinal hole after the colpectomy and prepares the Scarpa region (30 minutes) while Team 2 starts to roll the flap. The urethra is rolled over a catheter number 18 and the radial part of the flap is rolled over the neo urethra. This step lasts about 45 minutes.

Team 1 liberates the flap from the forearm and performs the anastomoses in a constant sequence: uretro-uretral, radial artery to femoral artery end-to-side, vena basilica, cephalica and accessoria and also one vena commitants radialis anastomosed end-to-end to the different veins of the saphenous group (45-60 minutes). The nerves anastomosis are done with fibrine glue. Team 2 covers the forearm defect with the full thickness skin graft. Dressing and monitoring. Follow-up, results and complications will be discussed.