Refinement Procedures for Clitorolabiaplasty in Male-to-Female Gender-Affirmation Surgery: More than an Aesthetic Procedure

Abstract

Background Among the various steps of a penile inversion feminizing genitoplasty, reconstruction of the clitoris and labia minora remains the most challenging procedure. Aim This study aims to evaluate surgical outcomes of neoclitoroplasty performed before and after the introduction of the labia minora’s creation in our surgical technique. Methods A retrospective analysis was carried out comparing 2 groups of patients that underwent penile inversion feminizing surgery: group A (64 patients) who had labia minora and clitoral hood creation and group B (103 patients) who did not. Outcomes To describe the surgical technique and outcomes of clitorolabiaplasty in male-to-female gender-affirmation surgery. Results Concerning overall complication rates, there were significant differences in the incidence of hemorrhage and urethral stenosis (P < .01). Hemorrhage surrounding the urethra and labia was identified in 40 patients (group A: n = 8 [12.5%]; group B: n = 32 [31%]) (P = .006). Neomeatal stenosis occurred in 17 patients (group A: n = 1 [1.5%]; group B: n = 16 [15.5%]) (P = .003). Partial necrosis of the clitoris occurred in 2 cases (group A: n = 0; group B: n = 2 [1.9%]) (P = .52). Necrosis of the labia majora occurred in 3 cases (group A: n = 0; group B: n = 3 [2.9%]) (P = .28). 5 patients (group A: n = 2 (3.1%); group B: n = 3 [2.9%]) (P = .93) developed rectovaginal fistula. 6 patients experienced neovaginal canal stricture (group A: n = 3 [4.6%]; group B: n = 3 [2.9%]) (P = .54). 2 patients (group A: n = 0; group B: n = 2 [1.9%]) (P = .52) reported introital stenosis; Persistent granulation tissue inside the neovagina that required in-office treatments occurred in 4 cases (group A: n = 2 [3.1%]; group B: n = 2 [1.9%]) (P = .62). Wound dehiscence occurred in 23 patients (group A: n = 13 [20.3%]; group B: n = 10 [9.7%]) (P = .05). 24 patients (group A: n = 3 [4.6%]; group B: n = 21 [20.3%]) (P = .004) underwent 28 different types of aesthetic refinements. Clinical Implications Incorporating the creation of labia minora and clitoral hood in one step is a safe and viable option in patients undergoing male-to-female gender-affirmation surgery. Strengths & Limitations Strength of the study is the large cohort of patients included and the consistent surgical technique. To our knowledge, this is the first study that compares with a control group, the introduction of labia minora creation in male-to-female gender-affirmation surgery. Limitations include the retrospective nature of the study and the absence of patient-reported outcomes measures. Conclusion Technical refinements of our technique led to a significative reduction in urethral stenosis and postoperative hemorrhage without an increased risk of major complications.

Gender‐affirming vaginoplasty: Technical considerations in patients with genital skin deficiency

“…The most commonly described method of augmentation to achieve adequate neovaginal depth was utilization of a full-thickness skin graft, typically using scrotal skin, but groin and lower abdominal wall skin were also often harvested. [8][9][10][11][12][13][14][15] This method is favored due to easily accessible graft tissue, relatively lower complication rates, and the advantage that graft harvest and integration require no to minimal additional technical skills than already in the armamentarium required for a PIV.…”