Volume 6, Number 4, 2002
The Aesthetic Vulva: Perineal Cosmesis in the Male-to-Female Transsexual
Neal Wilson, M.B. B.S., F.R.C.S.
Neal Wilson, M.D., P.C.
Twenty-three male to female (MfF) patients were asked to give their opinion on vulval aesthetics with reference to the photographs in Femalia (Blank, 1993). The results are illustrated and the author’s attempts to reach these impossible standards are illustrated. A literature search was conducted using the keywords: vulva, vagina, cosmetic, aesthetic, and transsexual and the results are annotated.
Keywords: vulva, vagina, cosmetic, aesthetic, transsexual
A Medline search of the literature of the last twenty years or so using keywords "vulva", "vagina", "aesthetic", "cosmetic", and "transsexual" yielded eight references for cosmetic (Rehman and Melman, l 999; Hage et al, 1996; Jarrar et al., 1996; Hage et al, 1994; van Noort and Nicolai, 1993; Eldh, 1993; Fang et al., 1992; Stein et al., 1990) and three references for neo-cliteroplasty (Hage et al., 1996; Rubin, 1993; von Szalay, 1990).
However, Hage’s review of the literature on neo-cliteroplasty in 1994 revealed thirty-seven references. Since 1985, initially in conjunction with James Pierce (Chairman of Urology, Wayne State University School of Medicine) I have used a portion of the glans penis carried on a corpus cavernosus flap with blood and nerve supply to the glans remnant via the dorsal penile arteries and nerves and to the residual corpus cavernosus via the non-ligated cavernosal arterial system (Figure 1.). So far, in the one hundred and ten of these procedures performed, there have been only three complete losses of the neo-clitoris. I also attempt to construct a clitoral hood and labia minora at a second stage; this requires as much penile skin as possible to be left on the outside, which in turn, requires a split skin graft or a recto-sigmoid segment at the initial procedure. I am still working to solve the issues of: size of the penile remnant neo-clitoris; penile skin being too thick to form the clitoral hood and labia minora; and the cosmetic appearance of the resulting vulva. The third issue involves the first two and is the subject of this discussion.
I used as a reference, "Femalia, Jaoni Blank, editor" which contains thirty-two unretouched photographs of vulvas. From March to May 2000, I asked all the post-operative and immediately pre-operative MtF patients to choose, without any limitation on number, which vulvas they thought were aesthetically most appealing, and which they would ideally choose for themselves. Twenty-three patients, eight of whom were African-Americans, rendered sixty-seven opinions. By far the most popular was the image on page eleven with twenty choices (Figure 2), with pages nine and thirteen, each with nine choices (Figures 3 and 4) tying for second and third place. Although this is not a scientific sample, it may give us a starting point. A brief analysis seems to suggest that the following are of importance: a relative paucity of pubic hair; a short, rather delicate clitoral shaft; relatively delicate, not florid, labia minora which form a continuum from the cleft in the ventral surface of the glans all the way around the posterior fourchette; a small but distinctive glans clitoris; a clitoral hood, conjoined to the labia minora, which can be retracted to reveal the glans; an elliptical posterior fourchette with no gaping of the vaginal introitus; a definite, rather flat perineum between the posterior fourchette and the anal margin and so on.
I find the major problems in construction to be the shortness and narrowness of the clitoral shaft, the smallness of the clitoral glans and the thinness and delicacy of the labia minora. My aim is to reduce the size of the penile remnant and I have now reduced down from the dorsal halves of the corpora cavernosa to the supero-lateral one third of one corpus cavernosus; while attempting to maintain blood supply and sensation, and, at the same time, folding up the flap so as to form a short clitoral shaft (Figure 5). However, I have not managed to construct delicate labia minora (the penile skin is too thick when doubled), which emanate from the underside of the glans, go all the way around the posterior fourchette and also have a conjoined, retractable clitoral hood.
The following illustrations portray my journey through the troubled waters of vulval aesthetics, particularly when the clitoris has to be a sensate structure coming down from above, rather than a urethral structure coming up from below.
Figure 6: The general appearance of the patient standing.
Figure 7: A ten-year follow-up on the original procedure which shows a too large clitoral shaft and glans. The posterior fourchette is a non-eliptical square block of scrotum, but there is some labia minora formation and a reasonable overall appearance.
Figures 8 and 9: An overall view of an original procedure patient which shows a much better posterior fourchette, but a still too large clitoral glans. The legs apart view shows labia minora and a partial clitoral hood but too florid external meatus.
Figure 10: A newer technique to show the construction of the eliptical posterior fourchette and a much reduced neo-clitoris. Please note the rolled-under peno-scrotal flaps medially, from which will come the tissue to construct the labia minora and clitoral hood.
Figure 11: This shows the same patient healed but before the second surgery. This is the smallest clitoris and glans I have so far produced.
Figures 12 and 13: This shows a patient with reasonable clitoris, labia minora and posterior fourchette. Please note the recto-sigmoid segment, which shows too much and causes the introitus to gape.
Figure 14: This is a patient of Middle-Eastern extraction and illustrates the problems of pubic hair. The glans is completely covered by a clitoral hood. Please note the too thick labia minora. The rest of the appearance is reasonable.
Figure 15: This shows good labia majora, an eliptical posterior fourchette, a non-gaping introitus, and in the legs-apart view, a well exposed small glans with reasonable clitoral hood and labia minora.
This small imperfect study of vulval aesthetics indicates that we still have far to go in the construction of a cosmetically acceptable vulva. The results shown above are some of the better and more recent of my results. However, I was recently at a meeting when someone, who shall remain nameless, said "My G**, this guy’s left the G***n penis behind", all the while showing his own results of simple penile inversions with the so-called clitoris beginning at the bulb of the penis and traveling superiorly. As an afterthought, I find that keeping a portion of corpus cavernosus helps the neo-clitoris to survive, which is contrary to some published reports; however, I choose not to argue with only three clitoral flap losses in one hundred and ten patients.
Blank, J. (1993) (ed.) Femalia, Down There Press: San Francisco.
Rehman, J. and Melman, A. (1999) Formation of neoclitoris from glans penis by reduction glansplasty with preservation of neurovascular bundle in male to female surgery: functional and cosmetic outcome. Journal of Urology, 161(1): 200–6.
Hage, J. J. and Karim, R. B. (1996) Sensate pedicled neocliteroplasty for male transsexuals: Amsterdam experience in the first 60 patients. Annals of Plastic Surgery, 36(6): 621–624.
Jarrar, K., Wolff, E., and Weidner, W. (1996) Long-term outcome of sex reassignment of male transsexual patients [in German ]. Urologe-Ausgabe A, 35(4): 331–337.
Hage, J. J., Karim, R. B., Bloem, J. J., Suliman, H. M., and van Alphen, M. (1994) Sculpturing the neoclitoris in vaginoplasty for male to female transexuals. Plastic and Reconstructive Surgery. 93(2): 358–64 [review] 93(2): 365 [discussion].
van Noort, D. E. and Nicolai, J. P. (1993) Comparison of two methods of vagina construction in transsexuals. Plastic and Reconstructive Surgery, 91(7): 1308–1315.
Eldh, J. (1993) Construction of a neovagina with preservation of the glans penis as a clitoris in male transexuals. Plastic and Reconstructive Surgery, 91(5): 895–900; 91(5): 901–903 [discussion], (1994) 93(3): 646–648 [comment].
Fang, R. H., Chen, C. F., and Ma, S. (1992) A new method of cliteroplasty in male to female sex reassignment surgery. Plastic and Reconstructive Surgery, 89(4): 679–682; 89(4): 683 [discussion], (1993) 91(7): 1364 [comment].
Stein, M., Tiefer, L., and Melman, A. (1990) Follow up observations of operated male to female transexuals. Journal of Urology, 143(6): 1188–1192.
Rubin, S. O. (1993) Sex-reassignment surgery male to female. Scandinavian Journal of Urology and Nephrology (Supplement), 154: 1–28.
von Szalav, L. (1990) Construction of a neo-clitoris in male to female transexuals. [in German]. Handchirurgie, Mikrochirurgie, Plastische Chirugie, 22(5): 277–278.
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