Surgical Therapy: Scrotal Reconstruction in Female-to-Male Transsexuals

Fig. 34.1

Scrotoplasty performed with direct skin expansion in the labia majora, with no flap surgery: the scrotum is located completely in between the legs

Today, most of the surgeons performing scrotoplasty in transsexual patients prefer techniques involving the use of labia majora flaps; since labia majora flaps are not bulky enough, testicular implants are usually needed and inserted in a later stage.

The labia majora, in fact, are the embryologic counterpart of the scrotum: these are both, in fact, matching for color and texture and hair bearing, and these have the same tactile and erogenous innervations.

Furthermore, the labia majora presents with fat tissue which can give adequate protection to the testicular implants [2].

For these reasons, labia majora flaps are overcoming many disadvantages posed by older techniques, such as the procedure results technically easier less additional donor site morbidity and better sensitivity [2].

With the introduction of labia majora V-Y plasties [1–3, 5–19], surgeons aimed to bring the scrotum in front of the legs and at the same time obtaining a natural sack-looking scrotum [2].

Figure 34.2 is showing a scrotoplasty performed with inferiorly based labia majora flaps, at the same time of a metoidioplasty. These flaps are simply harvested with subcutaneous fat, lifted downward, and sutured together. This ends into a scrotum in between the legs.

Fig. 34.2

Scrotoplasty performed with inferiorly based labia majora flaps, at the same time of a metoidioplasty

According to the Hoebecke’s novel technique for scrotoplasty [2], a V-Y 90° rotation labial plasty can bring the scrotum more in front of the legs. Today, their series constitute the largest and longest follow-up, with more than 240 operated patients with successful results.

This method is always performed at the same time of the phalloplasty, with no extra expansion needed.

Table 34.1 (modified from Selvaggi et al. [2]) is summarizing the most representative techniques described in the literature.

Table 34.1

Surgical techniques using labia majora flaps for scrotal reconstruction in transsexual patients

Authors	Flap’ s description	Advantages	Disadvantages
Gonzalez-Ulloa [5]	Bilateral advancement of M-like-incised skin flaps		Not aesthetically pleasing results: scrotum results in between legs
Snyder and Browne [8]	Bilateral skin flaps from perineum and medial aspect of the thighs (skin in the midline is deepithelialized, and closure is started laterally, incorporating a V-Y advancement)		Not aesthetically pleasing results: scrotum results more anteriorly than Gonzalez-Ulloa’ s technique, but still not in front of the legs
Hage et al. [1]	Labia majora incised in a reversed V-like manner; the skin of the dorsally based skin flaps is undermined; testicular prostheses are immediately inserted; skin is closed in a Y-like fashion		Not aesthetically pleasing results: scrotum results in between legs
Others (Millard [6]; Puckett and Montie [9]; Reid and Wright [13]; Meyer and Daverio [16]; Still and Goodman [20]; Exner [19]; Stark [21]; Hage et al. [1]; Small and Becker [22]; Sengezer and Sadove [23])	Different kinds of labial rotation and V-Y closure, with or without implants		Similar to previous techniques
			Few cases performed, or numbers not mentioned
			Some do not reconstruct urethra
Hoebeke’s technique (Selvaggi et al. [2])	Superiorly based bilateral V-Y flaps, rotated medially and bent on themselves	Increased possibility for local erogenous sensation (preserving the dorsal skin of the clitoris to create the anterior part of the scrotum)
		Possibility for orgasm during displacement of the clitoris at the base of the phallus (allowing for orgasm during masturbation or penetration)
		Better cosmetic result and positioning of the scrotum “in front of the legs”
		Better coverage for the reconstruction of the “pars fixa” of the urethra reducing urinary fistulas

34.1 Hoebecke’s Surgical Technique

This surgical approach is for scrotoplasty, vaginectomy, and reconstruction of the pars fixa in one stage, at the same time of a penile reconstruction, which is mostly performed with a free radial forearm flap by the authors of the technique. The same scrotoplasty technique can be used also in combination with other phalloplasty methods.

We hereby limit our description to the scrotoplasty step only.

The incision lines are marked on the borders of the labia majora and on top of the clitoris (Fig. 34.3). A total submucosal vaginectomy is performed.

Fig. 34.3

Drowning of the incision on the labia majora

A traction suture is placed on the tip of the clitoris, and the lengthening of the urethra is started incising and suturing together two vertical lines made on the internal side of the labia minora, approximately 2 mm laterally to the original urethral end.

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