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FRCS Plastic Surgery > CHAPTER 10: UROGENITAL > Flashcards

CHAPTER 10: UROGENITAL Flashcards

1
Q

Describe the embryology of the sexual organs

A

Prior to the 6th week of gestation the embryo is sexually indeterminate

Basic foetal model is female

SRY gene - present on Y-Chromosome → testes → Leydig cells (testosterone - male genitalia development) and Sertoli cells (removal of upper vagina and uterus)

If not → ovary

Virilization at 6-19 weeks gestation
After the 6th week the gonads arise from the genital ridges and differentiate into ♂+♀

The internal sexual organs form from the paramesonephric and mesonephric ducts.

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2
Q

What do the mesonephric and paramesonephric ducts form?

A

The Paramesonephric duct (Müllerian duct)
♀ = fallopian tubes, uterus, cervix and upper vagina
♂ = degenerates to form the appendix testis
Sertoli cells within the gonad secrete a testosterone analogue that acts as a Müllerian-inhibiting factor.

The mesonephric duct (Wolffian duct)
♂ = epididymis, ductus deferens, seminal vesicles, ejaculatory ducts
Leydig cells secrete testosterone which stimulates development of mesonephric duct and genital tubercle.

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3
Q

How do the external genital organs form?

Until when are they sexually indistinct?

A

wk3
cloacal membrane forms, fuses and forms genital tubercle

wk6
cloacal membrane divides into urogenital and anal membranes
cloacal folds divide into urethral and anal folds, with genital swellings laterally

o Central urethral groove
o Urethral folds on either side of the urethral groove.
o Labioscrotal swellings on either side of the urethral folds.
o The genital tubercle anteriorly
sexually indistinct up to this point

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4
Q

How does the male external genitalia form?

A

Wk 6-11
The genital tubercle elongates → penis
urethral groove grows distally down the genital tubercle, forming endoderm of the penile urethra almost to tip
Distal part of the urethra is initially formed by urethral plate (endoderm) & later replaced by ectodermal ingrowth from surface of glans penis canalising the glandular urethra and forming the external urethral meatus.

12th week → urethral folds fuse over the urethral groove, → tubed urethra from proximal-to distal.
labioscrotal swellings → scrotum, separated by scrotal septum.

7mths Testes usually descend into the scrotum

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5
Q

How does the female external genitalia form?

A

Genital tubercle → clitoris urethral groove does not extend into the genital tubercle.
The urethral folds do not fuse over urethral groove. Instead they form a hood over clitoris and labia minora.
The labioscrotal swellings form the labia majora

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6
Q

What is the anatomy of the penis?

A

Root
Body
Glans

ROOT
Bulb → corpus spongiosum
bulbospongiosus muscle
attaches to perineal body
empties semen and urine
contains urethra
Lateral crurae (2) → corpus cavernosum
ischiocavernosus muscle
causes erection
attaches to perineal memebrane
Bulbourethral glands
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7
Q

What are the layers of the penis at the body?

A 
Skin
Dartos fascia
→ superficial dorsal vein
Bucks fascia
→ deep dorsal vein, dorsal artery, dorsal nerve
Tunica albuginea
- corpus cavernosum - deep artery
- corpus spongiosum - artery to urethral bulb
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8
Q

What is the blood supply of the penis?

A

ARTERIES
Internal iliac
Internal pudendal
Artery to urethral bulb
→ Dorsal artery - supplies CC, skin, fascia, glans
→ Deep artery (cavernosal artery - erectile)

VEINS
deep dorsal vein → prostatic venous plexus
venae comitantes → internal pudendal
superficial dorsal vein → superficial external pudendal and great saphenous

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9
Q

What is the lymphatic drainage of the penis?

A

Superficial dorsal vein (skin) → superficial inguinal nodes

Glans and corpora → deep inguinal nodes → internal iliac nodes

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10
Q

What is the nerve supply to the penis?

A

Skin → posterior scrotal and dorsal br of pudendal

Glans skin → dorsal nerves

Ischiocavernosus and bulbospongiosus muscle → perineal branch of pudendal

Ejaculation → sympathetics (L1) sup & inf hypogastric plexi

Erection → parasympathetic pelvic splanchnic nerves to corpus cavernosum

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11
Q

What is the anatomy of the urethra?

A

3 parts

  1. prostatic
  2. membranous
  3. penile
  • transitional epithelium except part proximal to external meatus (stratified squamous)
  • external meatus → vertical split

3 constrictions

  1. internal meatus (bladder neck)
  2. prox end of navicular fossa
  3. external meatus
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12
Q

What are the fascial layers of the penis?

A

Colles fascia becomes Dartos and Bucks

  1. Dartos
  2. Bucks
  3. Tunica albuginea (tightly binds corpus cavernosum and corpus spongiosum)
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13
Q

What are the causes of chordee (ventral penile curvature)?

A

Ventral skin shortage
Inadequate urethral plate
Fibrous remnant of corpus spongiosum

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13
Q

What is hypospadias?

A

Hypospadias is a congenital condition of the penis characterised by:

  1. ventral meatus
  2. dorsal hood = hooded prepuce
  3. chordee = ventral curvature

May be associated with

  • paraurethral sinuses
  • urethral valves
  • flattened glans penis
  • deficient central skin
  • clefting of glans
  • scrotal bipartition
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14
Q

What are the embryological theories of hypospadias?

A

Failure of urethral folds coalesing in midline from base to tip (but what about glans?)

Baskin (2000) urethral folds fuse → seam of epithelium → canalises by apoptosis. Similar canalisation by apoptosis of glans
Prepuce - formed by growth of ridge of skin from corona. In hypospadias, urethral folds fail to fuse so prepuce is hooded
Chordee - dorsal tissue grows normally, ventral urethra and associated tissues are attenuated

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15
Q

What is the epidemiology of hypospadias?

A

1 in 300 live male births

Distal - no assocs

Proximal - assoc w

  • inguinal hernias (50%)
  • other GU tract (25%)
  • undescended testes (5% of all hypospadias, 31% of prox)
  • open processus vag 9%
  • upper GU tract abn 3%
  • FHx - 4-10%
  • IVF (4x more common)
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16
Q

What is the aetiology of hypospadias?

A

Genetic

  • father son 8%, sibling 14%
  • Androgen hyposensitivity
  • Androgen receptor deficiency

Environmental

  • increased oestrogens / plant oestrogens
  • IVF
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17
Q

How is hypospadias classified?

A 
Distal = 1-4 (85%)
Proximal = 5-9 (15%)

Ant 1-3, (75%) Mid 4-6, Post 7-9

  1. Glanular
  2. Coronal
  3. Subcoronal
  4. Distal penile shaft
  5. Mid penile shaft
  6. Proximal penile shaft
  7. Penoscrotal
  8. Scrotal
  9. Perineal
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18
Q

How is severity and subsequent management determined?

A
  • meatal position
  • quality of urethral plate
  • configuration of glans
  • degree of curvature
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19
Q

What are the goals of treatment?

A

Normal functioning penis and near-normal appearance
Function
- Micturition while standing with a non turbulent stream
- Normal sexual function
Appearance
- Natural appearance

Creation of a straight penis, with even calibre neourethra terminating in a natural slit-like meatus at the apex of a naturally reconfigured glans.
Foreskin preservation, may be requested → no long term FU studies of function
Is correction
o Functionally necessary?
o Aesthetically feasible?

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20
Q

When is surgery timed?

A

Antenatal screening and group education session
Assessment during 1st few wks of life → bond ω parents + make provisional plan

18-36 months not good time due to Ψ morbidity of genital surgery

Early – 6-18 months
o Stage 1 – 12 months, Stage 2 – 18 months
o Single stage 12 months
o Disadv - GA risk (OK after 6 months in paed centre)

Late – 36 months +
o Out of nappies, better pt understanding and cooperation
o Disadv - Ψ genitally aware after 18 months

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21
Q

What impt points are assessed in H&E?

A 
History
direction of stream, ballooning, flow
erection shape, size
FHx
IVF, exposure to oestrogens
Examination
foreskin - well / poor developed / absent
glans & groove - shallow, conical / deep
urethral plate - broad / narrow (<1cm)
penile size - normal / reduced
curvature - present / absent
meatal posn
penile torsion
scrotum - normal / hypoplastic / bifid / transposed
Hernial orifices
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22
Q

What tests / investigations are there for hypospadias?

A

Hortons & Turner-Warwick artificial erection tests

USS if proximal

Excretory urogram / voiding cystourethrography

Urine MCS (urethral valves → infection)

Testosterone gel ?enlarge glans & penis

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23
Q

What is the surgical management of hypospadias when urethral plate is adequate?

A

Choice of op determined by quality and development of urethral plate

URETHRAL PLATE TUBULARISATION
1. Glans Approximation Procedure
(Zaonz 1989)
- urethral plate tubularised, for distal hyp

  1. Tubularised Incised Plate Procedure
    (Snodgrass 1994)
    - midline dorsal releasing incision
    - urethral plate incised (self-epithelialises),
    - 2 lateral glans incisions, urethral plate flaps raised, tubularised and closed in 2 layers (w/o overlapping suture lines), glansplasty
    Barrier layers = spongiosum, dartos, tunica vaginalis
24
Q

What surgical procedures are recommended if urethral plate is inadequate?

A
  1. Urethral Plate Augmentation (Snodgraft)
    - free graft quilted into dorsal incised defect (instead of re-epithelialisation)
    - useful if glans more conical, with minimal groove and lacking external rotation of glans wings. TIP in these cases will get meatal stricture therefore graft better
  2. Urethral Plate Substitution (2 stage)
    Bracka (1995) - more predictable outcome
    Q: does urethral plate need transecting??
    best for significant ventral chordee (because full circumferential substitution urethroplasty is needed)
    1st stage = graft: inner prepuce, buccal mucosa (BXO) - min 15mm diameter, Nesbit procedure if needed or ventral tunica release & TV grafts
    2nd stage 6mths - 10mm = urethra, 5mm de-epithelialised and double-breasted
25
Q

What is the postop management?

A

Immediate

  • Dorsal penile block / ring block
  • Urinary diversion - 8-10 Fr children
  • Tegaderm dressing
  • Double nappy
  • .Antibiotics
  • Ketoconazole 400mg tds to control erections (or cyproterone)
  • Oxybutynin 1mg tds for bladder spasm

Follow- up

  • monitor for stenosis, fistulae, cosmetic, urinary stream
  • f/u 3/12 then 1-4yr, puberty
26
Q

What other operative techniques are you aware of for hypospadias correction?

A

Amputation distal to meatus!

Duplay 1874 - ventral releasing preputial skin flaps & urethral reconstruction - modified by Browne, Cecil Culp, Van der Meulen

Duckett - transverse preputial flap tubed

Harris - split prepuce flap

Elder & Duckett - islanded transposition preputial flap

Mattieu 1932 - parameatal (flip) flap
- modified by Mustarde, Devine & Horton: v-shaped midline glans flap advanced into meatus

Duckett 1981 - MAGPI - meatal advancement and glansplasty (distal & mobile meatus)

Snodgrass 1994 - TIP Urethroplasty

Bracka 1995 - 2 stage inner prepuce FTSG (or buccal, bladder mucosa, skin grafts)

Turner Warwick 1997 - Urethral dissection and advancement = BEAM Bulbar elongation and anastomotic meatoplasty

27
Q

What are the complications of surgery?

A

EARLY
bladder spasm, infection, haematoma, wound dehiscence, oedema, erections

LATE
fistulae (distal 5-10%, proximal 10-20%)
stricture (<5%)
meatal stenosis
UTI, residual urine
infertility / sexual dysfunction
hairy urethra from ventral skin flaps
BXO balanitis xerotic obliterans (lichen sclerosis) → phimosis, stenosis → SCC (chronic)
28
Q

What is epispadias and bladder exstrophy?

A

Congenital defect

  • anterior urethra terminates on dorsum of penis
  • abnormal development of cloacal membrane

Epispadias
♂ - dorsal meatus, short penis, dorsal chordee, divergent corpora
♀ - short vagina, cleft clitoris and wide labia minora
Exstrophy - absent ant wall, eversion of bladder

29
Q

What are the following conditions?

  1. Congenital penile curvature
  2. Chordee
  3. Cryptospadias
  4. Peyronie’s disease
A
  1. Abnormal fixation of penile skin / Dartos fascia - Nesbit procedure: tunica albuginea plication, excision
  2. fibrous remnant of corpus spongiosum causing ventral penile curvature & ventral skin shortage
  3. Growth deficiency (not fusion defect), preserved frenulum, dorsal hooding, oblique raphe, terminal meatus, inguinal hernia
  4. Upward curvature, thickening & fibrosis dorsal surface of tunica albuginea extending into septum b/t corpora - 4-5th decade, assoc w Dupuytren’s
30
Q

What is Peyronie’s disease?

A

A disease of the penis involving connective tissue
1% of men age 40-60

Characteristics

  • painful erections
  • penile curvature during erection
  • firm palpable nodule or inelastic plaque on penile shaft
  • 10% also have Dupuytren’s contracture
31
Q

How do you correct the deformity?

A

Reconstruction
Plication procedure
- circumcising incision and degloving of penile shaft tunica albuginea opposite area of maximum curvature identified and ellipse excised from each corporeal body
- tunica defects closed, shortens penis slightly

Dermal graft procedure

  • curvature greater than 45 degrees
  • degloving of penile shaft
  • incisions made through Buck’s fascia and mobilised off TA
  • disesaed TA (plaque) excised
  • dermal graft used to cover corporeal defects
32
Q

What treatment is available for penile enhancement?

A
  • Liposuction of fat pad
  • Division of suspensory ligament
  • VY skin advancement from pubic area
  • Dermofat onlay grafts around tunica to increase girth
  • Stretching with weights
33
Q

What is the management of ambiguous genitalia?

A

MDT - geneticist, paeds

  • Counsel parents, investigate, do not rush to assign incorrect sex
  • Assign sex by 2yrs
Causes
Enyzyme deficiencies
Karyotype problems
Congenital adrenocortical hyperplasia
Male pseudohermaphroditism
Mixed gonadal dysgenesis
True hermaphroditism
46XY Androgen insensitivity, 5α reductase def, 17 α hydroxy def
46XX CAH (21 hydroxylase def)
45XO Turners Syndrome
47XXY Klinefelter’s syndrome
45XO/46XY Mixed gonadal dysgenesis
46XY ♀ SRY gene mutation
46XX ♂ SRY gene mutation
34
Q

Vaginal agenesis

A

1 in 4000 live ♀ births
Failure of development of paramesonephric duct

Examine = vaginal dimple
USS = define kidneys, bladder and uterus, not good for vagina
IVP = exclude other UT abnormality
EUA - endoscopy and dye 
Chromosome analysis
Treatment
Pedicled Colon → mucous
Dilatation→ Frank 1938, sequential glass or plastic moulds
Local labial flaps Graves 1981
SSG reconstruction → McIndoe. SSG over a mould, labia minora then oversewn and the mould left in situ for 6 months
FTG over stent
Flaps of labia minora
Regional flaps such as gracilis
35
Q

Tell me about congenital vaginal defects

A

1:5000 births
defect in paramesonephric duct development or fusion of urogenital sinus with paramesonephric duct

Clinical examination and Investigations
True female, absent vagina, +/- functioning uterus, skeletal, urinary, GI abnormalities
Hermaphrodite

36
Q

How do you diagnose congenital vaginal defects?

A 
Diagnosis
pelvic / rectal examination
intravenous pyelogram
karyotype screening
spinal radiographs
37
Q

What are the methods of reconstruction in congenital vaginal defects?

A

Reconstruction
Frank’s technique – non-surgical autodilation
Malaga flap – vulvoperineal FC flaps
McIndoe procedure – dissect tunnel above rectum, below bladder vacity lined with SSG / FTSG, pt wears stents for yrs
Vascularised bowel segment – problems with mucous secretion and bleeding at intercourse
Other flaps – rectus abdominis, gracilis, pudendal thigh, inferior abdominal wall skin flap

38
Q

What indications are there for vaginal recon?

A

Congenital

  • absence (Rokitansky syndrome)
  • segmental (imperforate hymen, long segment atresia)
  • malformation → ♀ hypospadias

Acquired

  • Surgical ablation → e.g. mid section ex for prolapse
  • Radionecrosis → hostile tissues
  • Fistulae → requires flap closure
39
Q

What classification is there for vaginal defects?

What flaps can be used to reconstruct different defects?

A

Cordeiro Classification (PRS 2002)

IA Ant / lat wall → Singapore FC flap (Wee PRS 1989)

IB Post wall → VRAM (vertical skin paddle)

IIA Upper 2/3 → rolled VRAM (transverse upper abdo skin paddle)

IIB Total → bilateral gracilis

40
Q

What are the surgical options for vaginal recon?

A
  1. Preferred tissues → vagina, vulva, skin, jejunum
  2. Distant flaps
    o Wei → bilat groin flaps
    o TRAM → pedicled through pelvis on IEA
    o Bowel → but tend to get stenosis at mucocutaneous anastomosis
  3. Vulval tissue expansion
    o Appropriate tissue, no donor defect
    o 2 stages

Radionecrosis
o Need to import well vascularised tissue = TRAM, Omentum, Gracilis

41
Q

What is the blood supply of the female perineum?

A

Internal pudendal → perineal → posterior labial (good for perforator flaps)

42
Q

What are the considerations in perineal reconstruction?

A
  1. lining
  2. skin
  3. dead space
  4. herniation
  5. anal sphincter
  6. stomas
43
Q

What is the vascular supply of the perineum and how can flaps be designed?

A

Vascular anatomy and perforators of perineum.
SCIA, superficial circumflex iliac artery; SIEA, superficial inferior epigastric artery;
SEPA, superficial external pudendal artery;
DEPA, deep external pudendal artery;
OA, obturator artery;
PA, perineal artery;
** IPA, internal pudendal artery.

There are three ways of moving the local perforator flaps:
rotation (lotus petal flaps)
transposition (pudendal, mons pubis flaps)
V-Y advancement

44
Q

What flaps are used for perineal reconstruction?

A

Singapore flap (Wee PRS 1989)

Lotus petal flap (Yii, Niranjan BJPS 1996)

45
Q

Tell me how a lotus petal flap is designed and raised

A

Lloyd Davies’ position
catheter
Prophylactic antibiotics
defect created by resecting surgeons
flap is planned in a reverse manner by using a swab, and flap dimensions marked on donor site
perforator vessels are mapped using a handheld Doppler ultrasound probe at the base of the planned skin flap.
exploring incision is made along one edge of this flap down to the muscle.
The flap is elevated including the deep fascia.
The perforating vessel is reassessed.
In rotation or transposition flaps, the perforators should be selected closer to the defect. However, for V-Y advancement flaps, perforators can be anywhere in and around the midaxis of the V-Y flap.
Once the perforator is identified and in an axial flap, the subcutaneous vessels should be identified. Only then can the flap be islanded.
The advantage of islanding is that there is better mobility of the flap and avoidance of dog-ears at the pivot point.
The main disadvantage of island flaps is venous congestion, and this can be avoided by preserving some amount of subcutaneous tissue at the pivot point.
The flap can then be transposed, rotated, or advanced to the defect and sutured with absorbable sutures.
The donor site is almost always closed directly.
A suction drain should be inserted for the donor site and recipient site.

46
Q

What is the post op instructions and complications?

A

bulky gamgee
PCA first 3 days.
The thighs are kept abducted and the knees slightly flexed.
mobilise after 24 hours
TWOC day 3
No sitting initially, gradually on soft cushions.

Complications
infective
partial loss is usually as a result of venous outflow problems (leeches, release sutures, heal by secondary intention)

47
Q

Outline how to raise bilateral gracilis flaps for perineal reconstruction

A

Gracilis flap
mark flap with the patient standing and check in supine or lithotomy position.
Assess the gracilis origin and insertion and draw a line from the pubic tubercle to the distal semitendinosus tendon.
The skin paddle can be up to 10 cm wide, allowing primary closure of the donor site.
anterior incision first and raise the subcutaneous tissue as a flap anteriorly on the thigh. This allows for harvesting a larger portion of muscle fascia than that which directly underlies the skin paddle, capturing additional septocutaneous perforators.
As the fascia is elevated anteriorly, identify the gracilis tendon distally and confirm the location of the skin paddle directly over the proximal muscle by “bowstringing” the tendon. The saphenous vein remains anterior to the flap.
With the dominant proximal pedicle exposed, ligate and divide the distal pedicles from the superficial femoral artery.
Additional mobilization may be achieved by dissecting proximally to the profundus origin, dividing the branches that enter the adductor brevis and longus. This translocates the rotation point of the flap to approximately 7-8 cm below the pubic tubercle. Visualize and divide the obturator nerve.
The muscle is not divided at its attachments to the pubic tubercle unless required for mobilization, thus providing a secondary blood supply through the proximal branches of the obturator vessels.
The skin panel can be made into a complete island and tunneled into the perineum underneath the remaining perineal skin.
Myocutaneous flaps can be rotated clockwise from the left thigh and counterclockwise from the contralateral thigh. Perform this with the patient in the lithotomy position with the hips adducted 45° and slightly flexed 15° while the knees are flexed slightly, taking pressure off the peroneal nerve. If these flaps are used to restore the pelvic cavity, they can be tubed to create a neovagina.
de-epithelialise as necessary

48
Q

How do you raise a VRAM flap for perineal recon?

A

The rectus abdominis flap provides several advantages over bilateral gracilis flap reconstruction.
The robust skin paddle can be de-epithelialized for bulk or tubed for neovaginal reconstruction.
For large pelvic exenteration defects, the rectus abdominis muscle can be used alone or in combination with the de-epithelialized skin paddle
muscle bulk to obliterate pelvic dead space
skin island can be used for resurfacing the perineal region, including the vaginal wall.

The cutaneous paddle can be designed in various ways along the epigastric region using the superior subcostal musculocutaneous perforators of the upper abdominal wall.
The well-perfused region extends from below the costal margin to below the umbilicus and is approximately 20-25 cm long, directly overlying the rectus muscle.
The skin paddle of 8-10 cm width usually can be closed primarily. However, if a larger paddle is desired, skin grafting usually is necessary and may be tenuous over the fascial closure. Alternative skin paddle designs to the longitudinally based pattern include a transverse orientation.
If the pattern is to be de-epithelialized, this can be performed to resurface a large perineal defect. As the flap is elevated, the anterior fascia sacrifice remains somewhat narrower than the skin paddle. Thus, a strip of anterior rectus sheath, both lateral and medial, can be closed primarily.
Detach the rectus muscle from its superior attachments to the lower costal margin and divide the superior epigastric vessels with cautery. The flap must be mobilized sufficiently by dividing the inferior intercostal perforators.
After transposition into the perineal region through the pelvic defect, close the abdominal donor site. Use closed suction drains for both the donor and recipient sites.

49
Q

Split gluteus maximus flaps

Gluteal thigh flap

Regional fasciocutaneous flaps

A

Split gluteus maximus flaps

While many variations of gluteus maximus flaps have been described, the split gluteal flap is particularly useful in resurfacing pelvic defects.In this flap, only the superficial 1-1.5 cm of gluteal muscle is harvested, supplied by the proximal parasacral perforators. This allows elevation of the gluteal region primarily as a musculofascial cutaneous flap.

With the patient in the prone jackknife position, mark the flap based proximally on the sacral border along the direction of the gluteus muscle fibers for an appropriate width to cover the defect.
Elevate the flap from distal to proximal, splitting through the superficial 1-2 cm of the gluteus maximus muscle.
Carry dissection proximally to within 1 cm of the sacral border while the deep portion of the muscle remains in situ. The inferior gluteal artery is protected, and the inferior gluteal and sciatic nerves are deep to the plane of dissection. Bilateral elevation of these flaps may be required if the dead space is substantial.

Gluteal thigh flap

The gluteal thigh flap may provide a reliable, versatile reconstruction of perineal defects, with low donor site morbidity. This flap includes the inferior portion of the gluteus maximus muscle and encompasses the territory of the posterior thigh, directly supplied by the descending branch of the inferior gluteal artery.

The design of the flap is centered on the descending branch of the inferior gluteal artery. Outline the flap on the central axis of the posterior thigh, perpendicular to the gluteal crease, with the rotation point 5 cm above the ischial tuberosity. It extends to 5-7 cm above the popliteal fascia.
As the flap is elevated, divide the fascia lata and elevate the fascia overlying the hamstring musculature along with the posterior cutaneous nerve of the thigh.
Ligate deep perforators as dissection proceeds proximally and elevate the inferior portion of the gluteus maximus muscle, with the flap up to the lower border of the piriformis muscle. The flap may remain sensate and provides excellent cover for the perineal region. It may be de-epithelialized in its distal portion and tubed for distal vaginal reconstruction.
A disadvantage includes a “dog ear” formation at the medial rotation point, which may require secondary revision.

Regional fasciocutaneous flaps
The use of fasciocutaneous flaps in perineal reconstruction is well described and the vascular anatomy of the perineal region is quite distinct. The super-fascial plane contains 3-5 segmental musculocutaneous perforators from the superficial vascular plexus. Venous drainage is by way of vena comitantes, thus a proximally based fascial cutaneous thigh flap can be designed with the flap base located approximately 5 cm from the perineum to preserve proximal vascular supply. This allows for primary closure of the donor site. The anterolateral thigh perforator (ATP) flap has enjoyed recent success in perineal reconstruction. Pedicled ATP island flaps can be used for reconstructing perineal defects up to 20 cm in size. Although the vascular anatomy is quite variable, it is well-described as a septocutaneous or musculocutaneous perforator.

50
Q

What are the considerations for transgender surgery?

A

Goals

  • single stage
  • aesthetically pleasing
  • erogenous sensibility
  • minimal morbidity
  • the individual should be on hormonal therapy and introduced to society as their transgender status for a minimum of 2 yrs
51
Q

What are the surgical interventions for transgender surgery?

A 
Surgical interventions
Male to female
- breast augmentation
- rhinoplasty
- male pattern hair removal
- reduction of thyroid cartilage
- feminizing genital surgeries – penectomy, penile inversion, skin grafts, intestinal

Female to male
Surgical interventions
- breast amputation or reduction
- hysterectomy, oophorectomy
- phallus recon – pedicled flaps, free flaps, phalloplasty, urethral lengthening
- neoscrotum (perineal advancement flaps, labia majora flaps), testicular prosthesis

52
Q

What are the surgical options for vaginal recon in transexuals?

A

Epithelium lined cavity created between prostate/urethra/seminal vesicles and rectum

Urethra cut obliquely to prevent stenosis

Techniques
- Inversion of penis, or penis and scrotum skin flaps, most common, labia from scrotum
- SSG (McIndoe) with stents
- Perineal / abdo pedicled skin flaps
- Intestinal segments
Post Op
- Regular dilatation , stent, vibrator, intercourse

53
Q

What are the goals of penile recon?

A
  • one stage op, often microvascular recon
  • reproducible with predictable results
  • competent neourethra, allows micturition standing
  • restore penis with tactile and erogenous sensibility
  • enough bulk to insert prosthesis
  • achieve aesthetic result
54
Q

What are the reconstructive techniques of penis?

A 
Techniques
RFFF
scapular
groin
gracilis
free fibula osteocutaneous 
ulnar forearm
lateral arm
dorsalis pedis
abdominal flaps (rectus abdo myocutaneous/ DIEP)
urethral recon w SSG / FTSG from inner thigh, abdo or scrotum, grafts of saphenous vein, appendix, ileum, bladder
55
Q

What surgical options are available for neo-phalloplasty?

A

Abdo tubes
Local flaps -e.g. - abdominal and pubic
Gracilis
Free radial forearm - various designs, staged urethral recon and glansplasty

Penile implant for erection - need to wrap it in Dacron to allow anchoring to pubis
Testicular implants

56
Q

How do you treat a posterior trunk wound?

A 
Causes 
Tumour
Infection
Spina bifida
Spinal surgery wound dehiscence

OPTIONS
Upper 1/3 - trapezius myocutaneous flap (transverse cervical artery)
Middle 1/3 - LD (thoracodorsal pedicle)
Lower 1/3 - LD turnover, lumbar artery perforator, gluteus maximus / SGAP, bipedicled FC, keystone flaps
Tissue expansion
VAC and SSG

57
Q

How do you treat a newborn with spina bifida?

A

Types - occulta, meningocele, myelomeningocele
Aim - watertight closure, cosmesis

MDT
Op within 24-48hrs of birth
- mobilize edge of neural placode and separate from surrounding dysplastic skin
- placode is folded in on itself
- lumbosacral fascia is used as waterproofing layer
- multilayered closure is performed

Closure

  • direct
  • myocutaneous flaps (LD, glut max)
  • FC flaps
  • Perforator flaps
  • Periosteal turnover flaps

E.g. Large myelomeningocele
Local turnover fascial flaps, paraspinal muscle closure, midline skin closure / large bipedicle(s) from mid axillary line

58
Q

How do you treat an infected thoracolumbar wound after scoliosis surgery?

A 
Principles
Metalwork is retained
Debridement and closure if possible
Excisional debridement of non-viable tissue and bone
Specimens for culture
Closed suction drainage

Superior wounds - MC extended LD flap
Inferior wounds - gluteus maximus muscle islanded and rotated into defect

FRCS Plastic Surgery (63 decks)

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