Genital, Urinary, Gender Affirmation, Pelvic

Question 1

A 34-year-old man with schizophrenia is examined 1 hour after amputating his penis at the base of the shaft with a cleaver. The penis has been retrieved and a decision is made to attempt microvascular replantation. Repair of which of the following arteries is paramount to a successful outcome?

A) Bulbourethral
B) Deep cavernosal
C) Dorsal penile
D) Helicine
E) Internal pudendal

Answer 1

The correct response is Option C.

The blood supply to the penis arises from the internal pudendal arteries, which continue into the penis as the bulbourethral artery (supplying the bulb of the penis and penile urethra), the deep corporal/cavernosal artery (responsible for erection and supply to the penile shaft), and the dorsal penile artery (supplying the penile skin). A meta-analysis has shown that repair of the dorsal penile artery predicted the best combined sexual function, urinary function, and sensation outcomes. Repair of the deep corporal/cavernosal artery did not correlate with improved outcomes. The helicine artery is one of the terminal branches of the dorsal penile artery, and is distal to the site of amputation. The internal pudendal artery supplies the penis, but more proximal than the site of amputation.

Question 2

A 76-year-old woman presents with a diagnosis of recurrent adenocarcinoma of the rectum after chemotherapy and radiation. The planned oncologic surgical treatment will be an abdominoperineal resection to include the rectum, anus and posterior wall of the vagina, and left end colostomy. She has had a prior laparoscopic bowel resection, but no open abdominal surgeries. Which of the following is the most appropriate surgical management for her planned perineal wound?

A) Bilateral pudendal flaps
B) Omental flap and skin graft
C) Primary perineal closure
D) Right gracilis myocutaneous flap
E) Right vertical rectus abdominis myocutaneous flap

Answer 2

The correct response is Option E.

Abdominoperineal resection and pelvic exenteration in previously irradiated patients create a large-volume non-collapsible dead space in the pelvis that can lead to large persistent perineal wounds. Meta-analysis reviews of existing patient series report that primary perineal closure is associated with twice the rate of perineal wound formation as flap closure. When compared with thigh-based flaps, such as the gracilis flap and gluteal-based flaps, the vertical rectus abdominis myocutaneous flap is associated with lower perineal wound and flap complication rates.

With prior abdominal surgery, the omentum may not be available or of sufficient volume for reconstruction. A skin graft is often applied to the omentum for sternal wound reconstruction, but would not be appropriate for resurfacing of the posterior wall of the vagina in concert with an omental flap.

Bilateral pudendal flaps would be in the previously irradiated field, increasing the potential for wound healing trouble with this flap selection. Additionally, pudendal flaps would not bring the bulk necessary to address an abdominoperineal resection defect.

Question 3

A 51-year-old patient presents for male-to-female gender confirmation surgery. World Professional Association for Transgender Health (WPATH) guidelines have been met, and the patient is deemed a good candidate for penile inversion vaginoplasty. Which of the following is the most likely long-term complication of this procedure?

A) Neovaginal stenosis
B) Partial prolapse
C) Rectovaginal fistula
D) Urethrovaginal fistula
E) Urologic dysfunction

Answer 3

The correct response is Option A.

In contrast to female-to-male gender confirmation surgery, where complications of urological reconstruction and anastomosis are most common, in male-to-female gender confirmation surgery the most common complication is neovaginal stenosis. A recent literature review suggests that this is true for both penile inversion and bowel vaginoplasty.

Question 4

A 42-year-old woman is scheduled to undergo penile reconstruction with a fibula flap as part of gender reassignment. She has been evaluated by all appropriate specialists in the context of a multidisciplinary transgender clinic. Which of the following is the most significant advantage of the fibula flap over the forearm flap in this patient?

A) Ability to create an innervated skin island
B) Avoidance of prosthesis to provide sexual function
C) Decreased incidence of urethral stricture
D) Improved sensory recovery
E) More reliable and constant anatomy

Answer 4

The correct response is Option B.

The most significant advantage of the fibula flap over the forearm flap in penile reconstruction is the avoidance of a prosthesis to provide erectile and sexual function. Another advantage is the less conspicuous donor site. Both flaps allow for the creation of an innervated skin island. The fibula skin island can be innervated via the superficial peroneal nerve, and the forearm skin island can be innervated via the medial and lateral antebrachial cutaneous nerves. The forearm flap utilizes vascularized forearm skin for the neourethra, whereas the fibula flap employs a full-thickness skin graft. Thus, the incidence of urethral stricture is greater with the fibula flap. Both flaps are based on reliable and relatively constant anatomy, although the septocutaneous branch of the peroneal artery to the skin of the fibula flap can be variable or even absent. One disadvantage of the fibula flap is that sensation is not as good as with the forearm flap.

Question 5

A 58-year-old woman is evaluated for squamous cell carcinoma of the posterior vagina. Wide local excision of the vagina with flap reconstruction is planned. Which of the following flap options is most likely to provide a reconstruction that is sensate immediately after surgery?

A) Gracilis myocutaneous
B) Oblique rectus abdominis myocutaneous
C) Pedicled anterolateral thigh perforator
D) Pudendal thigh (Singapore)
E) Vertical rectus abdominis myocutaneous

Answer 5

The correct response is Option D.

The pudendal thigh flap is an axial patterned flap based on terminal branches of the superficial perineal artery. The superficial perineal nerve follows the course of this artery and becomes the posterior labial nerve to provide sensation to the proximal skin paddle. The superficial perineal nerve arises from the pudendal nerve. In a series of 19 patients who underwent pudendal thigh flap reconstruction, all reported sensation. The gracilis myocutaneous flap may provide some pressure sensation from cutaneous branches of the obturator nerve, although this is inconsistent. The anterolateral thigh perforator flap and vertical or oblique rectus abdominis myocutaneous flap may be neurotized to provide sensation; however, this would not result in immediate sensation.

Question 6

A 51-year-old female presents with recurrent endometrial carcinoma with a prior history of pelvic radiation. A total pelvic exenteration is planned with an ileal conduit and end colostomy. The patient would like to resume sexual intercourse after her treatment and on exam has significant perineal radiation changes. Which of the following reconstructive plans would be most appropriate for this patient?
A) Bilateral Singapore Flaps
B) Right unilateral vertical rectus abdominis myocutaneous flap (VRAM)
C) Unilateral posterior thigh flap
D) Bilateral gracilis myocutaneous flaps
E) Bilateral gluteus advancement flaps

Answer 6

Correct answer is option D.
The goals for reconstruction for this patient are total vaginal reconstruction, obliteration of pelvic dead space and control of the pelvic inlet to prevent pelvic hernia. Bilateral Singapore flaps can be used for total vaginal reconstruction but would be in the radiated field and would not be the best option for this patient. A VRAM would likely not be possible as most resecting surgeons site ostomies within the rectus muscle and this patient will require two ostomies. The posterior thigh flap is best suited to resurface the posterior vaginal wall and perineum and lacks the surface area for total vaginal reconstruction unless bilateral flaps are elevated. Bilateral gracilis myocutaneous flaps is the correct answer as the combined skin paddle can produce the 14-by-7-cm surface area of the vagina, the tips of the flaps can be approximated to the presacral fascia to protect the pelvic inlet, and in many patients can occupy the pelvic potential space following total pelvic exenteration. Gluteus advancement flaps would not accomplish the goals for reconstruction for this patient.

Question 7

A 56-year-old woman undergoes abdominoperineal resection secondary to aggressive rectal cancer. Neoadjuvant chemotherapy and radiation therapy have been performed. Surgical examination shows defect of the anus, rectum, and posterior vaginal wall. An intraoperative photograph is shown. Which of the following is the most appropriate reconstructive option in this patient?

A) Bilateral Singapore (pudendal thigh) flaps
B) Gracilis muscle flap
C) Omental flap
D) Rectus femoris flap
E) Vertical rectus abdominis musculocutaneous flap

Answer 7

The correct response is Option E.

As the treatment of anorectal cancers has shifted to more sphincter-preserving surgeries and radiochemotherapy, the need for abdominoperineal resection (APR) has decreased. However, in cases of locally persistent disease, involvement of nearby structures (vagina), or recurrent disease, there is an increased rate of survival and improved quality of life with pelvic extirpation. These cases typically result in problematic wounds secondary to previous radiation therapy, with complication rates as increased as 60%. Complications include delayed wound healing, infection, internal hernia, chronic sinus formation, and the psychological and physical concerns associated with vaginal resection in the female patient. In an effort to minimize these complications and restore sexual function in the female patient, musculocutaneous flap reconstruction is recommended.

In the patient described, the most appropriate option for reconstruction is the vertical rectus abdominis musculocutaneous (VRAM) flap.

The advantages of the rectus flap include an excellent and safe pedicle (Mathes/Nahai Type III flap), rapid technique, abundant well-vascularized tissue, wide arc of rotation, acceptable donor-site morbidity, and ease of access in relation to the APR procedure. The well-vascularized bulky tissue is effective in obliterating the pelvic dead space, minimizes the risk of internal herniation of the abdominal contents, and provides healthy tissue in the event of suture line dehiscence allowing more rapid healing by secondary intention if necessary. The disadvantages of the VRAM include lack of sensation in the vagina/perineum, loss of secretory function that may result in dyspareunia, abdominal weakness/hernia, and unsightly bulk in the perineum that may require a secondary debulking procedure for aesthetic improvement. In the patient described, the decision was made to close the perineal skin over the de-epithelialized flap. Another patient is shown below with a perineal skin paddle.

Primary closure is inappropriate secondary to the increased rate of complications and poor sexual function without reconstruction as noted above. Bilateral pudendal thigh (Singapore) flaps are a great option for vaginal or labial reconstruction in the congenital or ablative setting when there is not a need for a large volume of tissue. In this case, the flaps are not an option because of the need for bulky tissue, previous radiation therapy administered to the base of the flaps, and transection of the flap’s blood supply (posterior labial artery). The extended groin flap is inappropriate for the same reason.

A skin graft is not likely to be successful, given the patient’s radiation history and violation of the rectum.

Question 8

A 56-year-old man comes to the office because of recurrent and locally advanced rectal cancer 2 years after undergoing low anterior resection and adjuvant chemotherapy and radiation therapy. Surgical extirpation involving the external perianal skin, anus, rectum, and musculature of the pelvic floor is performed. Which of the following is the most appropriate method of perineal reconstruction in this patient?

A) Gracilis flap
B) Local propeller flap
C) Omental flap
D) Rectus abdominis musculocutaneous flap
E) Rectus femoris flap

Answer 8

The correct response is Option D.

In the clinical setting of the patient described, the method for perineal reconstruction that has the most evidence to support it is the vertical rectus abdominis myocutaneous (VRAM) flap. Omental flaps are effective for smaller defects that primarily involve internal structures. Primary skin closure, local advancement flaps, and propeller flaps are not ideal in the setting of prior radiation because of the high risk of wound-healing complications. Gracilis flaps are low in volume and may be useful for smaller defects, although bilateral flaps can be adequate for moderate-sized defects. This patient has a large composite defect that will benefit from the large volume and cutaneous component of a VRAM flap.

Question 9

A 32-year-old woman presents for evaluation of abnormal vaginal drainage from a rectovaginal fistula. Medical history includes multiple childbirths with episiotomies and two failed fistula repair attempts with local tissue leading to soft tissue loss within the perineal body and rectovaginal septum. Physical examination is difficult secondary to pain and shows a significant degree of inflammation in the vaginal and anorectal area. Her anal sphincter function is preserved, and she has had no other medical problems or previous surgeries. Which of the following is the most appropriate management strategy for this patient?

A) Abdominal perineal resection (APR) with pedicle vertical rectus abdominus muscle (VRAM) flap
B) Intestinal diversion with an ostomy
C) Placement of acellular dermal matrix along the posterior vaginal wall
D) Placement of a seton into the fistula
E) Rotation of a pedicle sartorius muscle flap into the defect

Answer 9

The correct response is Option B.

Rectovaginal fistulas are bothersome conditions and may be challenging to fix. Fistulas may result from local trauma including childbirth, surgical injury, or infection. If the cause is unclear, the patient should be evaluated for the possibility of inflammatory bowel disease or cancer. In this case, the fistula is a result of local trauma from childbirth and surgical episiotomies. The examination demonstrates that the perineal body and rectovaginal septum are significantly damaged with loss of tissue in the area. Additionally, there is significant inflammation in this area. In severe or refractory cases with suboptimal tissue conditions, a diverting intestinal ostomy may be valuable in controlling the stream of enteric contents away from inflamed tissue and the anticipated repair. Given the loss of tissue in this area, a flap will be needed. While there are a number of options, the gracilis muscle flap remains the most common flap for this purpose.

The sartorius muscle has segmental perfusion and is not amenable to transposition into the perineum. Various approaches have been tried for fistula repairs including bioprosthetics. However, given the extensive damage in the area it is unlikely that a nonvascularized option will work. Conservative measures, such as seton placement, may be useful for infection control but will not lead to closure given the significant inflammation and tissue loss. Finally, abdominal perineal resection is typically reserved for patients with cancer or severe benign disease with loss of anal sphincter function and continence.

Question 10

In a patient undergoing phalloplasty based on the radial forearm free flap, which of the following recipient nerves should the flap nerve be coapted to for erogenous sensation?

A) dorsal clitoral nerve
B) perineal nerve
C) pudendal nerve
D) posterior labial nerve
E) Ilioinguinal nerve

Answer 10

The correct answer is A) Dorsal clitoral nerve

Rationale:
For erogenous sensation in phalloplasty, the dorsal clitoral nerve is the preferred nerve to coapt. It plays a crucial role in sexual function by providing sensory input to the clitoris, and when coapted to the neophallus, it helps restore sexual sensation. This nerve is essential for erogenous sensation and contributes to the functionality of the reconstructed genitalia.
• A) Medial antebrachial cutaneous nerve: This nerve provides sensation to the medial forearm, but it is not used for erogenous sensation in phalloplasty.
• B) Lateral antebrachial cutaneous nerve: Like the medial antebrachial nerve, this nerve provides forearm sensation but is not involved in erogenous sensation.
• C) Posterior antebrachial cutaneous nerve: While this nerve provides sensory innervation to the posterior forearm, it does not provide erogenous sensation to the genital area.
• E) Ilioinguinal nerve: This nerve is typically used for tactile sensation but does not contribute to erogenous sensation.

References:
1. Peters BR, Richards HW, Berli JU. Optimizing innervation in radial forearm phalloplasty: consider the posterior antebrachial cutaneous nerve. Plast Reconstr Surg. 2023;151(1):202-206. doi:10.1097/PRS.0000000000009771
2. Calotta NA, Kuzon W, Dellon AL, Monstrey S, Coon D. Sensibility, sensation, and nerve regeneration after reconstructive genital surgery: evolving concepts in neurobiology. Plast Reconstr Surg. 2021;147(6):995e-1003e. doi:10.1097/PRS.0000000000007969.
3. Morrison SD, Massie JP, Dellon AL. Genital sensibility in the neophallus: getting a sense of the current literature and techniques. J Reconstr Microsurg. 2019;35(2):129-137. doi:10.1055/s-0038-1667360

Question 11

According to the World Professional Association for Transgender Health Standards of Care guidelines, which of the following gender confirmation procedures requires two formal referral letters from mental health professionals before planning the surgical procedure?

A) Mastectomy
B) Pectoral implant surgery
C) Rhinoplasty
D) Testicular prosthesis implantation
E) Thyroid cartilage grafting

Answer 11

The correct response is Option D.

Transgender is a term used to describe a person whose gender identity differs from the sex that they were assigned at birth. For those with gender dysphoria, they may transition to their identified gender through a variety of medical and surgical approaches. To alleviate gender dysphoria, a multidisciplinary treatment plan is necessary. This includes social, psychological, medical, and surgical approaches. The mental health professional is critical in the evaluation and treatment of individuals with gender dysphoria. The World Professional Association for Transgender Health Standards of Care guidelines recommend two formal referral letters from mental health professionals before genital surgical treatment. Chest surgery requires one formal referral letter. However, facial surgeries do not require referral letters.

Question 12

Feminization of the forehead in a transgender woman most commonly addresses which of the following key skeletal features?

A) Cortical thickness
B) Frontal bone width
C) Frontal bossing
D) Low radix
E) Metopic ridge

Answer 12

The correct response is Option C.

Facial feminization surgery addresses many aspects of the facial skeleton and soft tissues. The forehead surgery can include hairline reduction and brow lift for the soft tissue as well as frontal sinus setback and reduction for supraorbital rim. Male patients develop enlarged frontal sinus compared with female patients during puberty, as well as thicker lateral supraorbital rims. Men also have a raised radix and overall thicker bone. Although the thickness of the entire skull can be thicker in men, reduction and contour in feminization surgery focuses on the frontal bone and lateral supraorbital rim.

Question 13

What are the exit points of the superior gluteal and inferior gluteal artery perforators respectively with regard to the posterior superior iliac spine (PSIS)?
A) Two Thirds of the distance from the greater trochanter to the PSIS and half the distance from the ischial tuberosity to the PSIS
B) One half of the distance from the greater trochanter to the PSIS and two thirds of the distance from the ischial tuberosity to the PSIS
C) Two Thirds of the distance from the ischial tuberosity to the PSIS and one half the distance from the greater trochanter to the PSIS
D) One half the distance from the ischial tuberosity to the PSIS and two thirds the distance from the greater trochanter to the PSIS

Answer 13

Correct answer is option a.
Using the posterior superior iliac spine (PSIS) for surface topography can be helpful when planning gluteus advancement flaps for pelvic reconstruction. The superior gluteal artery perforator zone begins at a location two thirds the distance from the greater trochanter to the PSIS above the pyriformis and the inferior gluteal artery perforator zone begins at a point half way between the ischial tuberosity and the PSIS. The inferior gluteal artery perforator zone will be more commonly isolated for pelvic reconstruction of abdominoperineal resection defects and should be a fasciocutaneous flap in the ambulatory patient to avoid weakening the hip extension function of the inferior gluteal muscle.

Question 14

A 35-year-old man is brought to the emergency department for penile amputation at the base of the shaft. The amputated part has been appropriately transported with the patient. Revascularization of which of the following vessels will result in the highest probability of successful replantation?

A) Bulbar artery and vein
B) Cavernosal artery and vein
C) Deep dorsal arteries and vein
D) Internal pudendal artery and vein

Answer 14

The correct response is Option C.

The most important vessels to anastomose in this clinical scenario are the deep dorsal arteries and vein. There are two deep arteries and one deep vein. There is a superficial dorsal vein as well, but no superficial dorsal artery runs with it. The vascular supply of the penis is from the internal iliac system, not the external iliac system. The internal pudendal artery comes off the anterior division of the internal iliac artery and is the main blood supply to the penis. It branches into the bulbar, cavernosal, and dorsal penile arterial branches. The other vessels listed are all involved in the blood supply to the penile structure, but are too small, less accessible, or too proximal for replantation purposes. The deep dorsal vessels alone can adequately revascularize the whole penile structure. The steps in replantation include: formation of a suprapubic urinary diversion, urethral anastomosis over a Foley catheter, corporal body coaptation by approximating the tunica albuginea, microsurgical anastomosis of the dorsal vessels and coaptation of the dorsal nerves, and skin closure.

Question 15

The deep inferior epigastric artery arises from which of the following arteries?
A) External iliac
B) Femoral
C) Internal iliac
D) Internal mammary
E) Superficial inferior epigastric

Answer 15

The correct answer is option a.
The deep inferior epigastric artery and vein arise from the external iliac artery at a point just proximal to where the artery passes beneath the inguinal ligament. The internal mammary vessels provide the regional source for the superior epigastric artery. The femoral, internal iliac, and superficial inferior epigastric arteries are not source vessels for the deep inferior epigastric artery and vein. The femoral artery originates as the external iliac vessels exit from the inguinal ligament. The internal iliac artery supplies blood to structures within the pelvis.

Question 16

A 20-year-old otherwise healthy individual who has a diagnosis of gender dysphoria would like to undergo masculinization of the chest for female-to-male transition. According to the World Professional Association for Transgender Health (WPATH) Standards of Care, which of the following criteria should be fulfilled before the patient can be cleared for such a procedure?

A) The patient should be at least 21 years of age
B) The patient should have completed 12 months of hormone therapy
C) The patient should have health insurance coverage
D) The patient should have lived 12 months in a male gender role
E) The patient should have one letter of support from a mental health professional

Answer 16

The correct response is Option E.

The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) lists having one letter of support from a qualified mental health professional as a prerequisite for female-to-male (FTM) chest surgery. As for all of the SOC, the criteria for initiation of surgical treatments for gender dysphoria were developed to promote optimal patient care. While the SOC allow for an individualized approach to best meet a patient’s health care needs, a criterion for all breast/chest and genital surgeries is documentation of persistent gender dysphoria by a qualified mental health professional. For some surgeries, additional criteria include preparation and treatment consisting of feminizing/masculinizing hormone therapy and one year of continuous living in a gender role that is congruent with one’s gender identity. Based on the available evidence and expert clinical consensus, different recommendations are made for different surgeries. For FTM chest surgery, the criteria are as follows:

Persistent, well-documented gender dysphoria

Capacity to make a fully informed decision and to consent for treatment

Age of majority in a given country (if younger, follow the SOC for children and adolescents)

If significant medical or mental health concerns are present, they must be reasonably well controlled

Hormone therapy is not a prerequisite

One referral

For male-to-female breast surgery, it is recommended to have completed 1 year of hormonal therapy, although it is not a specific criterion according to WPATH SOC. For genital surgery, it is recommended to have two referrals, be on 1 year of hormonal therapy, and to have lived in the gender role congruent with their gender identity for at least 1 year. Insurance coverage is not part of any WPATH SOC.

Question 17

A 40-year-old transgender woman (assigned male at birth) undergoes penile inversion vaginoplasty for treatment of gender dysphoria. She hopes to gain the ability for penetrative intercourse following surgery. She was counseled on the risks of surgery to include urethral injury, rectal injury, and fistula formation. Which of the following is the most appropriate plane in which to dissect the neovaginal cavity so that those risks may be minimized while obtaining adequate depth for penetrative intercourse?

A) Anterior rectal fascia
B) Prostatic capsule
C) Rectoprostatic fascia (Denonvilliers’ fascia)
D) Rectosacral fascia (Waldeyer’s fascia)
E) Superficial perineal fascia (Colles’ fascia)

Answer 17

The correct response is Option C.

The most appropriate plane in which to dissect the neovaginal cavity in gender affirming vaginoplasty is within Denonvilliers’ fascia, also known as the rectoprostatic fascia. This is a relatively avascular plane that separates the rectum and prostate until reaching the peritoneal fold, when performing the dissection perineally. Once the peritoneal fold is reached, a neovaginal cavity with depth compatible with penetrative intercourse is created.

Dissecting along the prostatic capsule may inadvertently lead toward the prostatic urethra. Injury to the urethra at this level may result in a urethrovaginal fistula and urinary incontinence.

Colles’ fascia is a superficial perineal plane that is continuous with Scarpa’s fascia of the inferior abdomen. Dissection along this plane is necessary initially until the central tendon and perineal body is opened to enter Denonvilliers’ fascia. Dissecting through Colles’ fascia alone and not through Denonvilliers’ fascia will avoid urethral and rectal injury, but will not permit penetrative intercourse in such a short neovaginal cavity.

Dissection along the rectal fascia will expose the longitudinal muscle fibers of the rectum. Not only does this increase the risk of sharp rectal injury during dissection, it will also increase the risk of pressure injury to the rectum when stenting the neovaginal cavity lining and in case of a hematoma. This is not the recommended plane for neovaginal cavity dissection.

Waldeyer’s fascia, also known as the rectosacral fascia, is a presacral fascia along the posterior aspect of the rectum. This is not an anatomic position to create a neovaginal cavity, and therefore is not the recommended plane for dissection.

Question 18

A 32-year-old patient, who was born as a female, identifies as male and requests breast reduction surgery for a masculine appearance. The patient has C-cup breasts with grade 2 ptosis. Which of the following is the most appropriate surgical option?

A) Liposuction
B) Periareolar breast reduction
C) Circumvertical breast reduction
D) Wise pattern breast reduction
E) Mastectomy with free nipple graft

Answer 18

The correct response is Option E.

The most appropriate treatment for this patient is a free nipple graft and mastectomy due to breast size and nipple ptosis. Gender dysphoria is a commonly acknowledged disorder, affecting up to 0.3% of the population. Hundreds of patients have undergone subcutaneous mastectomy surgery with a high reported patient satisfaction rate. Smaller-sized patients can achieve excellent results with periareolar mastectomy or donut excision to reduce large areola size. Large patients with ptosis, similar to gynecomastia surgery, require longer scars for skin removal and have good results, but longer scars. One study of outcomes found that patients and surgeons preferred the outcome appearance with free nipple graft and a single inframammary crease scar versus an extended areola incision with scars across the mid chest.

Neither liposuction nor periareolar reduction would adequately reduce the skin envelope and breast tissue. Circumvertical and Wise pattern breast reduction would create a more feminized shape.

Question 19

A 25-year-old woman comes to the office to discuss labiaplasty because of
discomfort and dissatisfaction with the appearance of her labia. Examination
shows asymmetry and prominence of the labia minora and clitoral hood. An edge
labiaplasty and clitoral hood reduction are planned. Dissection in which of the
following anatomic areas presents the greatest risk for sexual dysfunction and
permanent injury to the sensory nerves in this patient?
A ) Anterior clitoral hood
B ) Clitoral frenulum
C ) Interlabial sulcus
D ) Lateral clitoral hood
E ) Vaginal fourchette

Answer 19

The correct response is Option A.
Knowledge of the neuroanatomy of the vulvar area is essential for successful outcomes in
labiaplasty and clitoral hood reduction surgery. Sensation to the clitoris is carried in paired
dorsal nerves located in the anterior clitoral hood between the 2 o’clock and 11 o’clock
positions. These nerves run just below the superficial fascia of the clitoral hood and can be
injured if resection is more than skin-only. In contrast to “skin-only resection” of the clitoral
hood, edge resection of excess labia minora is a full thickness resection. Temporary sensory
changes are normal and usually resolve in weeks to months without sexual dysfunction.
The lateral clitoral hood would not contain these dorsal nerves; however, the skin is lax and
mobile, and skin-only resections should be done throughout the clitoral resection. The clitoral
frenulum is an extension of the labia minora to the clitoris. Most excision techniques end the
resection at the frenulum. The interlabial sulcus is the crease between the labia majora and
minora. Resection of the labia minora is not in the sulcus and usually begins at least 1 cm
distal to the sulcus. The vaginal fourchette is the posterior extension of the labia minora
where the two sides merge in a V-shaped skin fold.

REFERENCES:
1. Placik OJ, Arkins JP. A prospective evaluation of female external genitalia sensitivity to
pressure following labia minora reduction and clitoral hood reduction. Plast Reconstr
Surg. 2015;136(4):442e-452e. doi:10.1097/PRS.0000000000001573
2. Placik OJ, Devgan LL. Female genital and vaginal plastic surgery: an overview. Plast
Reconstr Surg. 2019;144(2):284e-297e. doi:10.1097/PRS.0000000000005883
3. Kelling JA, Erickson CR, Pin J, Pin PG. Anatomical dissection of the dorsal nerve of the
clitoris. Aesthet Surg J. 2020;40(5):541-547. doi:10.1093/asj/sjz33

Question 20

A 30-year-old man presents following sharp, self-inflicted amputation of his penis at the middle of the shaft. After counseling, he elects to undergo penile replantation. Anastomosis of which of the following arteries must be performed to ensure a successful penile replant and survival of the preputial skin?

A) Cavernosal
B) Dorsal
C) External pudendal
D) Internal pudendal
E) Urethral

Answer 20

The correct response is Option B.

Penile replantation and survival is based on arterial flow supplied by the anastomosis of the dorsal artery. The preputial skin and glans are perfused by terminal branches from the dorsal artery. The dorsal artery is able to perfuse the remainder of the penis through circumflex arteries. The cavernosal artery, by itself, is insufficient for penile replantation and results in significant skin necrosis. Similarly, the urethral artery does not supply the skin of the penis. The internal and external pudendal arteries both provide blood supply to the penile shaft but are not present at the middle of the shaft.

Question 21

Which of the following structures provides motor innervation to the gracilis free muscle flap?
A) Anterior branch of the obturator nerve
B) Femoral nerve
C) Inferior branch of the superior gluteal nerve
D) Medial femoral cutaneous nerve
E) Median sural nerve

Answer 21

The correct answer is option a.
The anterior branch of the obturator nerve provides motor innervation to the gracilis free muscle flap. This nerve branch courses between the adductor longus and adductor brevis tendons to innervate the gracilis muscle. The femoral nerve innervates the rectus femoris muscle at the level of the thigh, while the inferior branch of the superior gluteal nerve supplies motor innervation to the tensor fascia lata. The medial femoral cutaneous nerve, which is a branch of the femoral nerve, supplies sensory innervation to the medial thigh flap. The median sural nerve is found below the knee and courses parallel to the lesser saphenous vein.

Question 22

A 62-year-old female with a history of rectal cancer and comorbidities including hypertension and diabetes mellitus undergoes abdominoperineal resection (APR). She has a history of radiation therapy to the pelvic region. Given the significant pelvic dead space created by the procedure, which of the following would be the most appropriate approach for perineal reconstruction?

A) Primary perineal closure
B) Gracilis muscle flap
C) Vertical rectus abdominis myocutaneous flap
D) Pudendal thigh flap
E) Omental flap

Answer 22

The correct answer is C) Vertical rectus abdominis myocutaneous flap.

The vertical rectus abdominis myocutaneous (VRAM) flap is commonly used for perineal reconstruction following APR, especially in patients with comorbidities such as hypertension, diabetes, and prior radiation. However, while it provides robust tissue and vascularity, it is associated with an increased risk of abdominal hernia due to its effect on the abdominal wall integrity. The VRAM flap is less ideal in elderly patients or those with poor abdominal wall strength, as it may create long-term complications such as hernia formation. Nevertheless, in patients without these concerns, it remains a reliable option for preventing pelvic complications like fluid collections and hernias in the pelvic cavity, as well as decreasing wound dehiscence.

Incorrect options:
• A) Primary perineal closure: Primary closure may not be sufficient in patients undergoing pelvic exenteration or APR, as it cannot adequately fill the pelvic dead space and can lead to wound dehiscence and infection. It has higher rates of complications compared to flap-based reconstruction.
• B) Gracilis muscle flap: This flap may be too small to fill the pelvic dead space effectively and is not capable of providing robust tissue coverage for large perineal defects. While it can be used for smaller defects, it has limitations in larger pelvic reconstructive needs and may fail to prevent complications like hernias.
• D) Pudendal thigh flap: The pudendal thigh flap is also too small to adequately cover the large perineal defect following APR. Its limited tissue bulk and length make it unsuitable for this type of reconstruction.
• E) Omental flap: While the omental flap has been used in pelvic reconstruction, it requires a second incision and is less reliable than muscle or myocutaneous flaps. Additionally, its bulky nature and risk for complications like seroma formation or infection make it less favorable for perineal reconstruction after APR.

References:
1. Devulapalli C, Jia Wei AT, DiBiagio JR, et al. Primary versus flap closure of perineal defects following oncologic resection: a systematic review and meta-analysis. Plast Reconstr Surg. 2016;137(5):1602-1613. doi:10.1097/PRS.0000000000002107
2. Wilson TR, Welbourn H, Stanley P, Hartley JE. The success of rectus and gracilis muscle flaps in the treatment of chronic pelvic sepsis and persistent perineal sinus: a systematic review. Colorectal Dis. 2014;16(10):751-759. doi:10.1111/codi.12663

Question 23

In a patient who is undergoing dissection of a gracilis musculocutaneous flap, the gracilis muscle can be identified immediately posterior to which of the following muscles in the thigh?
A) Adductor longus muscle
B) Adductor magnus muscle
C) Pectineus muscle
D) Sartorius muscle

Answer 23

The correct answer is option a.

In order to effectively identify the gracilis muscle prior to flap harvest, the patient should be placed in the supine position with the knee in abduction. With the patient in this position, the adductor longus muscle can be palpated before surgery. Following incision, the gracilis muscle is easily identified posterior to the adductor longus. The adductor magnus muscle lies posterior to the gracilis, and the pectineus muscle is found anterior to the adductor longus at the floor of the femoral triangle. The sartorius muscle overlies the gracilis muscle distally.

Question 24

One month after chondrolaryngoplasty for facial feminization, the patient reports that the pitch of her voice is lower than before surgery. She does not have hoarseness. Which of the following structures was most likely injured?

A) Anterior commissure tendon
B) Arytenoid cartilage
C) Cricothyroid membrane
D) Hyoepiglottic ligament
E) Recurrent laryngeal nerve

Answer 24

The correct response is Option A.

Transgender women (assigned male at birth) who underwent puberty without hormone blockade often have enlarged thyroid cartilage as is seen in cis-males. Chondroplasty of the tracheal cartilage can decrease the prominence referred in lay terms as the “Adam’s apple.” A crease proximal or distal to the area of prominence is used for the approach. Perichondrium is often raised overlying the area of reduction and the excess prominence superior to the vocal cords and anterior commissure is reduced by burr or knife. Endoscopy may be used to verify the location of the anterior commissure to avoid injury to the vocal cords. Anterior commissure tendon injury leads to a deepened voice. Setback of the commissure is a treatment for high-pitched voices. A recurrent laryngeal nerve injury would result in hoarseness. The arytenoids are posterior and should not be encountered with the reduction procedure. The hyoepiglottic ligament connects the epiglottis to the hyoid bone; it assists with elevation of the epiglottis and is not involved with voice pitch. The cricothyroid membrane is the membrane that is entered for emergency airways. It is located inferior to the vocal cord structures and should not cause lowering of the voice.

Question 25

A 17-year-old transgender man (birth-assigned female) seeks female-to-male (FtM) transgender top surgery. The patient has been receiving testosterone therapy for one year through a pediatric endocrinologist. Patient, legal guardians, medical physician, and care team agree that bilateral mastectomy is indicated. Psychological evaluation for appropriateness for surgical consultation is pending. Which of the following statements correctly describes the patient’s ability to consent for FtM top surgery as a minor?

A) A favorable psychologic evaluation alone can establish the appropriateness of a minor for top surgery
B) A minor can consent for surgery without co-signature by another guardian or legal entity
C) As a minor, the patient does not require psychologic evaluation before proceeding with surgical consultation
D) The consensus agreement of the care team, psychologist, guardian, and patient is sufficient to consider a minor a candidate for top surgery
E) The patient is a minor and should not have transgender surgery

Answer 25

The correct response is Option D.

The patient is a minor who presents for consideration of female-to-male (FtM) top surgery. The World Professional Association for Transgender Health (WPATH) describes the criteria for documenting persistent gender dysphoria. A multi-disciplinary team including psychologists, endocrinologists, primary medical physicians, and plastic surgeons are critical to this process.

All patients considering transgender surgery require a psychologic evaluation to determine the appropriateness for surgical consultation whether they are a minor or adult. For minors considering top surgery, it is imperative that the patient, care team, psychologists, and guardians together believe that the delay of top surgery would cause harm. With this criterion satisfied, the addition of the suggested one year of testosterone treatment would further qualify this patient for candidacy for top surgery as a minor. A psychologist alone cannot establish the appropriateness of a patient to undergo a specific operation but can establish that a patient is ready for surgical consultation. Breast binders are used by a proportion of FtM patients to conceal their breasts. While this practice can improve social confidence, breast binding stretches the upper pole skin, creating more ptosis and worsening elasticity of the breast.

After confirmation of breast breast health, mastectomies and skin recontouring are performed for top surgery. Subsequent breast hypertrophy is not a concern as the entire breast gland is removed so surgical intervention, if deemed appropriate, does not need to be delayed until breast hypertrophy is complete.

Question 26

A 16-year-old transmasculine (female-to-male) patient is evaluated for bilateral mastectomy for gender confirmation. According to the World Professional Association for Transgender Health (WPATH) Standard of Care Guidelines, this procedure is considered to be medically necessary, appropriate, and indicated when which of the following conditions is met?

A) The patient has the capacity to make a fully informed decision
B) The patient has had 6 months of continuous hormone therapy
C) The patient has one physician who can document gender dysphoria
D) The patient has recently started pharmacologic therapy for depression
E) The patient must be at least 21 years of age

Answer 26

The correct response is Option A.

The criteria among most insurance plans for coverage of procedures for treatment of gender dysphoria are quite stringent and rely on the concept of medical necessity for the patient. According to the World Professional Association for Transgender Health (WPATH), which is considered the authority on transgender health, standard-of-care guidelines to verify medically necessary procedures include:

• -the capacity of the patient to make a fully informed decision and provide consent (patients who are younger than 18 may provide assent, along with parental consent, for mastectomy)
• -at least 12 months of hormone therapy, consistent with the individual’s gender goals
• -living life fully in the role of the desired sex for at least 12 months
• -psychiatric illnesses must be stable and well-controlled
• -documentation of gender dysphoria and the potential benefit from surgery by at least two health-care providers

Question 27

A 38-year-old ambulatory male presents with recurrent anal squamous cell carcinoma after chemotherapy and radiation treatment. The surgical plan for the patient is an abdominoperineal resection with left-sided end-colostomy. Which of the following surgical reconstructions would be most appropriate for this patient? (Copy)
A) Bilateral inferior gluteal myocutaneous advancement flaps
B) Bilateral inferior gluteal fasciocutaneous advancement flaps
C) Bilateral superior gluteal myocutaneous advancement flaps
D) Bilateral superior gluteal fasciocutaneous advancement flaps

Answer 27

The correct answer is option B.
The gluteus maximus muscle and the overlying skin are supplied by the superior and inferior gluteal vessels. The superior half of the muscle stabilizes the hip and the inferior half helps extend the hip, especially when climbing stairs. The nerve supply to both halves of the gluteus muscle travels with the inferior gluteal vascular pedicle. As a result, preservation of the inferior half of the gluteus muscle and the accompanying nerve is critical in the ambulatory patient. Superior gluteal advancement flaps with or without muscle are not ideal for perineal reconstruction as they are positioned closer to lumbosacral defects rather than the inferiorly positioned APR defect. Therefore the correct response is bilateral inferior gluteal fasciocutaneous flaps among the options listed here and its effectiveness and ease of use in reconstruction of APR defects has been demonstrated.

Question 28

A 56-year-old female with a history of advanced rectal cancer underwent an abdominoperineal resection, including a posterior vaginectomy, resulting in a type IB vaginal defect. She has a history of prior abdominoplasty and bilateral medial thigh lifts. The surgical team plans to reconstruct the perineal defect to provide stable skin coverage, repair the posterior vaginal mucosal defect, and obliterate the pelvic dead space. What is the most appropriate reconstructive option for this patient?

A. Vertical rectus abdominis myocutaneous (VRAM) flap
B. Transverse upper gracilis flap
C. Pudendal flap
D. Anterolateral thigh (ALT) flap
E. Profunda artery perforator (PAP) flap

Answer 28

Correct Answer: D. Anterolateral thigh (ALT) flap

The anterolateral thigh (ALT) flap is the most appropriate reconstructive option for this patient. Reconstruction following abdominoperineal resection with posterior vaginectomy requires a vascularized tissue transfer to provide stable coverage, obliterate the pelvic dead space, and repair the posterior vaginal mucosal defect. The patient’s prior surgeries preclude the use of several common flaps, including:
1. Vertical rectus abdominis myocutaneous (VRAM) flap: This option is not viable due to her history of abdominoplasty, which compromises the vascular integrity of the abdominal donor site.
2. Medial thigh flaps (PAP, transverse upper gracilis, pudendal): These are unsuitable because of the patient’s history of bilateral medial thigh lifts, which disrupt the donor site anatomy and compromise flap viability.

The ALT flap, however, remains a reliable and versatile option. It provides ample soft tissue coverage, robust vascular supply, and flexibility in shaping and positioning, making it ideal for reconstructing complex pelvic and perineal defects. Furthermore, it is harvested from an uninvolved donor site, minimizing the risk of donor site morbidity in this patient.

Delaying reconstruction or choosing a less optimal flap would increase the risk of complications such as wound dehiscence, infection, or persistent pelvic dead space, all of which could significantly impact the patient’s recovery and quality of life.

References:
1. Perrault D, Kin C, Wan DC, Kirilcuk N, Shelton A, Momeni A. Pelvic/perineal reconstruction: time to consider the anterolateral thigh flap as a first-line option? Plast Reconstr Surg Glob Open. 2020;8(4):e2733. doi:10.1097/GOX.0000000000002733
2. Horch RE, Ludolph I, Cai A, Weber K, Grützmann R, Arkudas A. Interdisciplinary surgical approaches in vaginal and perineal reconstruction of advanced rectal and anal female cancer patients. Front Oncol. 2020;10:719. doi:10.3389/fonc.2020.00719
3. Arquette C, Wan D, Momeni A. Perineal reconstruction with the profunda artery perforator flap. Ann Plast Surg. 2022;88(4):434-439. doi:10.1097/SAP.0000000000002986

Question 29

Which of the following virilizing changes is reversible if testosterone therapy is discontinued after the post-puberty male phenotype is achieved in affirmed male patients who were assigned female at birth?

A) Cessation of menses
B) Clitoromegaly
C) Lowered pitch of voice
D) Male-pattern baldness

Answer 29

The correct response is Option A.

The use of hormone replacement therapy for medical transitioning in transgender individuals is considered generally safe in the short- and medium-term settings, but many answers about lifetime therapy remain unknown, particularly in the arenas of cancer and aging effects. When counseling patients about the benefits, risks, and consequences of medical transitioning, it is essential that the practitioner is honest about the limitations of knowledge at this time.

Most guidelines for the use of testosterone in transgender men note that there are short-term changes in BMI, systolic blood pressure, and, potentially, liver chemistry that should be watched closely initially. Long-term monitoring centers on lipids (HDL, LDL) and polycythemia.

The initial virilizing effects of testosterone manifest in lowering of the voice, increased muscle mass with decreased body fat, development of acne, cessation of menses, and development of increased body hair and facial hair. While changes can start to appear in 3 to 6 months, it may take up to 5 years for the full post-puberty male phenotype to be achieved. Removing testosterone at this point is not generally recommended and continued hormone therapy for life is considered reasonable.

If hormones are stopped after reaching post-pubertal male phenotype, lowering of voice, growth of clitoris, increased hair distribution, and male pattern hair loss that have occurred will not be reversed. Menstruation can resume. Long-term effects on fertility are unknown, but pregnancy has been achieved by transgender men in their late 20s. Use of testosterone and cessation of menses IS NOT sufficient birth control to prevent pregnancy.

Question 30

A 56 year old woman with recurrent cervical cancer now invading the vagina after pelvic radiation is scheduled to undergo total vaginectomy and completion hysterectomy. She presents to discuss options for vaginal reconstruction. She is morbidly obese with a BMI of 48, a large peri-umbilical hernia and no prior abdominal surgery. On examination she has significant soft tissue thickness of the thighs and abdomen. Of the following options which would be the most appropriate method for total vaginal reconstruction?
A) Right vertical rectus adbominis myocutaneous flap
B) Bilateral gracilis myocutaneous flaps
C) Free jejunal flap
D) Bilateral Singapore flaps

Answer 30

The correct answer is option C
All of the options above have been used to perform total vaginal reconstruction. However the significant adiposity of her abdomen would preclude the folding of the flap required for circumferential vaginal reconstruction. Similarly significant soft tissue thickness of the gracilis flaps would make passage of both flaps through the pelvis difficult and should be considered on a case by case basis for morbidly obese patients. A free jejunal flap or a pedicled jejunal flap based on the fourth superior mesenteric artery (SMA) would fit in the pelvis and provide circumferential vaginal reconstruction. If vascular congestion of the pedicled flap is noted, the pedicled jejunal flap can be supercharged through the second SMA vascular arcade anastomosed to either the inferior epigastric system or a saphenous vessel loop using the femoral system. Bilateral Singapore flaps can be used for vaginal reconstruction but would be within the radiated field of this patient and could exhibit partial flap loss and/or delayed wound healing.

Question 31

A 67-year-old woman presents 6 months after right lower eyelid basal cell carcinoma excision reconstruction with wedge excision and closure. She reports epiphora. On examination, her scar is immature but healed, and she has an ectropion of the right lower eyelid. Displacement of the punctum in which of the following directions is the most likely cause of epiphora in this patient?

A) Anterior
B) Lateral
C) Medial
D) Posterior

Answer 31

The correct response is Option A.

The correct answer is anterior displacement of the punctum. The lacrimal drainage system is divided into proximal and distal segments; the proximal segment consists of the punctum, canaliculus, and common canaliculus. The lower external punctum is 6.5 mm from the medial canthus, 0.3 mm in size, and dorsally directed. This dorsal positioning allows it to drain tears effectively. The upper punctum is 6 mm from the medial canthus, so the puncta are not in apposition when the eyelids are closed. When the eyelids are open, the ampulla is dilated, and when the eyelids close, tears are pushed through to the common canaliculus.

A postoperative ectropion, common after lower lid surgery, will cause the punctum to be anteriorly displaced, thus limiting its ability to drain tears effectively. Medial or lateral displacement do not, in general, cause epiphora. While excessive posterior displacement could theoretically also cause dysfunction of drainage, the ectropion makes this unlikely.

Question 32

A 35-year-old affirmed male (birth-assigned female) presents to the office requesting top surgery for a more masculine chest appearance. On examination, the patient has a large C-cup breast, grade 2 ptosis, and a nipple-to-inframammary fold distance of 11 cm. Which of the following surgical options is the most appropriate?

A) Circumvertical reduction mammaplasty
B) Liposuction alone
C) Mastectomy with free nipple graft
D) Periareolar reduction mammaplasty
E) Wise pattern reduction mammaplasty

Answer 32

The correct response is Option C.

The most appropriate surgical procedure in this patient is a subcutaneous mastectomy with free nipple graft due to breast size and ptosis. Top surgery, or excision of the female breast tissue and shaping of the male chest, is often the first surgical procedure for female-to-male transgender patients. This marks the beginning of their surgical transition into a masculine phenotype and is associated with profound and impactful psychological and aesthetic benefits for the individual. The goal of top surgery is to produce a normal-appearing male chest. This is achieved by removing the breast parenchyma, obliterating the inframammary fold, reducing the areolar size, and positioning the nipple-areola complex into the appropriate position.

There are numerous studies demonstrating excellent results and high patient satisfaction with subcutaneous mastectomy and free nipple grafts in patients with large and ptotic breasts. Additionally, patients with a BMI over 27 kg/m2 and a nipple-to-inframammary fold distance greater than 7 cm demonstrate better outcomes with fewer complications. Periareolar breast reduction also demonstrates excellent results when limited to patients with smaller breasts, minimal ptosis, and a smaller skin envelope.

Liposuction alone will not achieve the goals above and will result in residual breast tissue and excess skin. Additionally, liposuction will not address areolar size or position. Liposuction is useful when combined with other techniques to help feather tissue thickness and contour the edges of the chest. Both Wise pattern and circumvertical reduction mammaplasty will leave behind too much breast tissue and will not create the desired masculine chest appearance.

Question 33

An otherwise healthy, 20-year-old transgender woman (assigned male at birth) has received appropriate psychological and hormone suppression therapy since prepuberty. She is now being worked up for male-to-female genital reaffirmation surgery. Which of the following is the most appropriate surgical management if penetrative intercourse is desired?

A) Intestinal vaginoplasty
B) Metoidioplasty
C) Penile inversion vaginoplasty
D) Radial forearm free flap
E) Surgery is contraindicated for this patient

Answer 33

The correct response is Option A.

The most appropriate management is intestinal vaginoplasty.

Many techniques are used in the creation of the neovaginal canal. Though there is no single optimal technique, inversion vaginoplasty with penile-scrotal flaps is the preferred and most commonly practiced method among surgeons. However, sufficient penile-scrotal skin is not always available because of limitations in either patient anatomy or patient expectations for vaginal depth. Additionally, it is becoming more common for younger patients to undergo hormonal blockade in anticipation of gender transition. This may limit the amount of tissue for penile-scrotal based vaginoplasty. Rectosigmoid vaginoplasty uses a section of the sigmoid colon to create the vaginal lining. Because this method doesn’t rely on penis size for vaginal depth, it is preferred in cases where sufficient penile tissue is lacking (phallus length of less than 4.5 in or 11.4 cm) or in patients who require revision of a failed primary vaginoplasty.

Metoidioplasty and a radial forearm free flap are methods used in the creation of a phallus in a transmale patient. As long as the patient is healthy, the age of consent, and meets the standards set by the WPATH (World Professional Association for Transgender Health), they are candidates for surgery.

Question 34

The dominant pedicle of the gracilis muscle flap is located between the adductor longus and which of the following muscles?
A) Adductor brevis
B) Adductor magnus
C) Pectineus
D) Sartorius
E) Semitendinosus

Answer 34

The correct answer is option a
The dominant pedicle of the gracilis muscle flap is located between the adductor longus and adductor brevis muscles. The pectineus, adductor magnus, sartorius, and semitendinosus muscles are anatomically incorrect relative to the location of this pedicle. Although the origin of the dominant vascular pedicle to the gracilis muscle flap may originate from either the profundus femoris or medial circumflex femoral vessels, the course of this vascular pedicle is consistent and runs between the adductor longus and adductor brevis muscles. This vascular pedicle enters the gracilis muscle approximately 8 to 10 cm below the pubic tubercle. The superficial position of the gracilis muscle, its thin, ribbon‑like character, and also its consistent vascular anatomy allow this muscle flap to remain one of the most useful muscles in the field of microvascular surgery. Although the dominant vascular pedicle easily nourishes the entire muscle, the distal third of the skin overlying the gracilis muscle does not receive sufficient blood supply for reliable transfer.

Question 35

A 53-year-old man has a chronic draining sinus of the perineal region one year after undergoing abdominoperineal resection of a low-lying rectal carcinoma followed by localized radiation therapy. Following debridement of the affected area, which of the following is the most appropriate management?
A) Healing by secondary intention
B) Primary closure
C) Skin grafting
D) Coverage with a fasciocutaneous flap
E) Coverage with a muscle flap
F) Both D and E

Answer 35

The correct answer is option F.
In a patient who has a chronic, irradiated wound, the most appropriate management is coverage with a muscle or musculocutaneous flap with a vascular pedicle that lies outside the field of radiation, such as the gracilis flap. Secondary intention healing is unlikely to be successful in a radiated wound bed, and primary closure of a previously radiated, nonhealing wound will also not result in appropriate healing. Skin grafting will be ineffective due to the poor vascularity of the wound bed. A well vascularized fasciocutaneous flap (ie Anterolateral thigh flap) provides equally as effective coverage as a muscle flap to fill the dead space within the wound.

Question 36

A vastus lateralis muscle flap elevated on its dominant pedicle provides reliable coverage for each of the following anatomic sites EXCEPT the:
A) acetabulum
B) groin
C) knee
D) perineum
E) trochanter

Answer 36

The correct answer is option C.

When the vastus lateralis flap is based on its dominant pedicle, the descending branch of the lateral femoral circumflex artery, it has an area of rotation that will provide vascularized coverage of the lower abdomen, groin, perineum, ischium, trochanter, and acetabular fossa. However, the flap must be reversed in order to rotate and provide coverage of knee defects. When used in this manner, the flap is then based on a branch of the lateral genicular artery, which is a minor distal pedicle. Because the risk for partial flap loss is greater, this flap is not often advocated for coverage of knee defects.

Question 37

A 21-year-old patient comes to the office seeking genital surgery for female-to-male gender confirmation. The patient is an appropriate candidate for phalloplasty with a radial forearm free flap. Which of the following is the most common complication of this technique?

A) Dissatisfaction with the aesthetic result
B) Formation of urethral strictures and fistulas
C) Inability to void while standing
D) Lack of sensation in the neophallus
E) Partial or total flap loss

Answer 37

The correct response is Option B.

The radial forearm free flap is the most commonly used technique for phalloplasty. A neophallus with a length of 7.5 to 14 cm can be reconstructed. The tube-within-a-tube design is commonly employed, in which the flap is tubed to create a neourethra over which the remainder of the flap is tubed to create the bulk of the flap. The clitoris is de-epithelialized and placed under the neophallus. Vascular anastomosis of the radial artery is performed to the inferior epigastric or femoral vessels. The medial and lateral antebrachial cutaneous nerves are coapted to the ilioinguinal nerve and the dorsal nerve of the clitoris or deep pudendal nerve to provide tactile and erogenous sensation.

The goals of phalloplasty are: creation of an aesthetically pleasing neophallus, with tactile and erogenous sensation, the ability to micturate while standing, and the ability to perform penetrative sexual intercourse.

The most common complications of phalloplasty are urologic, with an incidence of approximately 40%. A recent review of radial forearm free flap phalloplasty showed an average rate of fistula formation of 26.58% and strictures of 12.27%. The most common location for fistulas and strictures is at the anastomosis of the fixed urethra and the phallic urethra. Approximately half of these can be managed nonoperatively, with suprapubic catheter placement and endoscopic fistula dilation. Another recent systematic review of radial forearm free flap phalloplasty showed that 69% of patients reported erogenous sensation and 77% reported tactile sensation in their neophallus. Another review showed that standing micturition was achieved in 97.5% of patients and successful penetrative sexual intercourse was reported by 21.1%. The overall rate of partial flap loss was 5.43% and total flap loss was 1.69%. Overall 70% of patients reported satisfaction with the aesthetic result.

Question 38

In a patient undergoing phalloplasty based on the radial forearm free flap, which of the following recipient nerves should the flap nerve be coapted to for tactile sensation?

A) posterior femoral cutaneous nerve
B) perineal nerve
C) pudendal nerve
D) posterior labial nerve
E) Ilioinguinal nerve

Answer 38

The correct answer is E) Ilioinguinal nerve

Rationale:
In phalloplasty based on the radial forearm free flap, the ilioinguinal nerve is the most appropriate nerve for coaptation to provide tactile sensation to the reconstructed phallus. The ilioinguinal nerve, which exits through the external inguinal ring, supplies sensation to the skin over the mons pubis and labia majora. It is a suitable donor nerve for tactile sensation in genital reconstructive surgery.
• A) Medial antebrachial cutaneous nerve: While this nerve provides sensation to the medial aspect of the forearm, it is not typically used for tactile sensation in genital reconstructive procedures like phalloplasty.
• B) Lateral antebrachial cutaneous nerve: This nerve is also derived from the forearm and provides sensation to the lateral forearm, but it is not the ideal donor nerve for tactile sensation in phalloplasty.
• C) Posterior antebrachial cutaneous nerve: Although this nerve can be considered for nerve coaptation in radial forearm free flap phalloplasty, it is not primarily chosen for tactile sensation when compared to the ilioinguinal nerve.
• D) Dorsal clitoral nerve: This nerve is used for providing erogenous sensation, not for tactile sensation. It is essential for sexual function but not for general tactile sensation in the neophallus.

References:
1. Peters BR, Richards HW, Berli JU. Optimizing innervation in radial forearm phalloplasty: consider the posterior antebrachial cutaneous nerve. Plast Reconstr Surg. 2023;151(1):202-206. doi:10.1097/PRS.0000000000009771
2. Calotta NA, Kuzon W, Dellon AL, Monstrey S, Coon D. Sensibility, sensation, and nerve regeneration after reconstructive genital surgery: evolving concepts in neurobiology. Plast Reconstr Surg. 2021;147(6):995e-1003e. doi:10.1097/PRS.0000000000007969.
3. Morrison SD, Massie JP, Dellon AL. Genital sensibility in the neophallus: getting a sense of the current literature and techniques. J Reconstr Microsurg. 2019;35(2):129-137. doi:10.1055/s-0038-1667360

Question 39

A 16-year-old girl presents to your clinic with concerns of not having started her menstrual cycle (primary amenorrhea). She reports normal breast development and pubic hair growth. On physical examination, she has normal external female genitalia. Pelvic ultrasound reveals an absence of the uterus and upper third of the vagina, with normal-appearing ovaries. Laboratory studies show normal sex hormone levels, including testosterone concentrations in the normal female range. She has no hearing loss, renal abnormalities, or congenital cardiac defects. What is the most likely diagnosis in this patient?

A. Complete androgen insensitivity syndrome (CAIS)
B. Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome type 1
C. Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome type 2
D. Klinefelter syndrome
E. McKusick-Kaufman syndrome

Answer 39

Correct Answer: B. Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome type 1

Patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome exhibit a 46, XX female chromosomal pattern and a congenital disorder of the reproductive tract, resulting from Müllerian duct aplasia. This disorder is characterized by the underdevelopment or absence of the uterus and vagina. During normal embryologic development, the Müllerian ducts form the uterus, fallopian tubes, cervix, and upper third of the vagina. However, in MRKH syndrome, these structures fail to develop appropriately, though the ovaries function normally, and external genitalia are typically normal.

At puberty, patients with MRKH syndrome typically experience normal development of secondary sexual characteristics, such as breast development and pubic hair growth, but they do not begin menstruating, presenting with primary amenorrhea. Hormone levels, including testosterone, remain within the normal female range. MRKH syndrome is classified into two types: Type 1, which affects only the reproductive organs, and Type 2, which is associated with other anomalies, such as hearing loss, renal abnormalities, or cardiac defects.

The patient in this scenario presents with MRKH syndrome Type 1, characterized by the absence of the uterus and vagina. Vaginal agenesis, which may occur alone or with uterine agenesis, can be diagnosed through physical examination, ultrasonography, or MRI studies. Management options for vaginal agenesis include nonsurgical vaginal dilation or surgical vaginal reconstruction to facilitate sexual function.

In contrast, partial and complete androgen insensitivity syndromes (PAIS and CAIS) are characterized by mutations in the androgen receptor (AR gene), leading to a mismatch between the patient’s genetic sex (46, XY) and phenotypic characteristics. Patients with CAIS present at birth with female external genitalia but may have a small or absent vagina. PAIS patients may display a combination of male and female characteristics. Both groups have undescended testes and elevated testosterone levels, leading to primary amenorrhea. Imaging studies typically reveal absent uterus, fallopian tubes, and ovaries.

Klinefelter syndrome, caused by the presence of an extra X chromosome (47, XXY), results in male reproductive organs and small testes, often accompanied by primary testicular insufficiency.

McKusick-Kaufman syndrome affects females and presents with hydrometrocolpos, postaxial polydactyly, and congenital cardiac defects. Hydrometrocolpos is a rare condition due to distal vaginal obstruction, typically caused by an imperforate hymen, and classified into five types depending on the underlying defect.

References:
1. Herlin MK, Petersen MB, Brännström M. Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome: a comprehensive update. Orphanet J Rare Dis. 2020;15(1):214. doi:10.1186/s13023-020-01491-9
2. Londra L, Chuong FS, Kolp L. Mayer-Rokitansky-Küster-Hauser syndrome: a review. Int J Womens Health. 2015;7:865-870. doi:10.2147/IJWH.S75637
3. Gulía C, Baldassarra S, Zangari A, et al. Androgen insensitivity syndrome. Eur Rev Med Pharmacol Sci. 2018;22(12):3873-3887. doi:10.26355/eurrev_201806_15272
4. Nieschlag E, Ferlin A, Gravholt CH, et al. The Klinefelter syndrome: current management and research challenges. Andrology. 2016;4(3):545-549. doi:10.1111/andr.12208
5. Slavotinek AM. McKusick-Kaufman syndrome. In: Adam MP, Everman DB, Mirzaa GM, et al., eds. GeneReviews®. University of Washington, Seattle; 2002. Updated December 3, 2020. https://www.ncbi.nlm.nih.gov/books/NBK1502/
6. Chen MC, Chang YL, Chao HC. Hydrometrocolpos in infants: etiologies and clinical presentations. Children (Basel). 2022;9(2):219. doi:10.3390/children9020219

Question 40

A 28-year-old transgender woman presents to the plastic surgery clinic with concerns about her facial appearance. She reports significant gender dysphoria, particularly related to her hairline and forehead. On examination, she has a high hairline, a prominent brow, and an Ousterhout type 3 forehead. She desires a more feminine appearance and is seeking surgical intervention. Which of the following surgical interventions is most appropriate for this patient?

A. Augmentation cranioplasty
B. Frontal sinus setback with burring
C. Rhinoplasty
D. Mandibular contouring
E. Lip augmentation

Answer 40

Correct Answer:
B. Frontal sinus setback with burring

Rationale:
Gender-affirming facial surgery is an increasingly common surgery in the United States. The patient described has gender dysphoria centered around her hairline and forehead region with a high hairline, a prominent brow, and an Ousterhout type 3 forehead. The Ousterhout classification describes the anatomy of the forehead and frontal sinus and the intervention required to adequately feminize the forehead. The most common type is a type 3 forehead (80%) characterized by a prominent brow region and a thin anterior table of the frontal sinus. Patients with type 3 foreheads require frontal sinus setbacks and burring to create a feminine-appearing forehead. Augmentation cranioplasty is not indicated in type 3 foreheads.

Dang BN, Hu AC, Bertrand AA, et al. Evaluation and treatment of facial feminization surgery: part I. forehead, orbits, eyebrows, eyes, and nose. Arch Plast Surg. 2021;48(5):503-510. doi:10.5999/aps.2021.00199

Eggerstedt M, Hong YS, Wakefield CJ, Westrick J, Smith RM, Revenaugh PC. Setbacks in forehead feminization cranioplasty: a systematic review of complications and patient-reported outcomes. Aesthetic Plast Surg. 2020;44(3):743-749. doi:10.1007/s00266-020-01664-8

Ousterhout DK. Feminization of the forehead: contour changing to improve female aesthetics. Plast Reconstr Surg. 1987;79(5):701-713. doi:10.1097/00006534-198705000-00003

Question 41

A 28-year-old female presents for labiaplasty due to discomfort and aesthetic concerns. During the procedure, the surgeon plans to reduce the size of the labia minora. The patient expresses concern about potential complications, particularly regarding the clitoral region. Which of the following surgical approaches is most appropriate to minimize the risk of clitoral destabilization and anterior rotation?

A. Extending the labia minora excision up to the clitoral frenulum to ensure symmetry.
B. Performing a central anterior clitoral hood dissection deep to the superficial fascia for better exposure.
C. Trimming the clitoral frenulum to create a smoother transition between the clitoral hood and labia minora.
D. Limiting the posterior excision to avoid extending across the vaginal fourchette.
E. Keeping the clitoral frenulum intact and performing lateral clitoral hood reduction if needed.

Answer 41

The correct answer is option E.
The clitoral frenulum is an extension of the clitoral hood that usually attaches to the upper third of the labia minora. Dividing the clitoral frenulum can result in anterior rotation of the clitoris and subsequent painful chafing. There may be occasions when minor trimming of the frenulum is performed for a smoother transition; however, the frenulum is kept intact. When clitoral hood reduction is required, the excision is usually performed over the lateral clitoral hood. If dissection is performed over the central anterior clitoral hood, care is taken to stay superficial to the superficial fascia (dartos fascia) in order to protect the underlying nerves and vasculature. Extending the labia minora excision up to the clitoris can divide the frenulum and destabilize the clitoris, causing anterior rotation and chafing. Therefore, keeping the clitoral frenulum intact and performing lateral clitoral hood reduction, if needed, is the most appropriate approach to minimize complications.

References:

Furnas HJ, Graw GJ, Cho MJ, Othman S, Graw B, Percec I. Safety in female genital plastic surgery. Plast Reconstr Surg. 2020;146(4):451e-463e. doi:10.1097/PRS.0000000000007349

Escandón JM, Duarte-Bateman D, Bustos VP, et al. Maximizing safety and optimizing outcomes of labiaplasty: a systematic review and meta-analysis. Plast Reconstr Surg. 2022;150(4):776e-788e. doi:10.1097/PRS.0000000000009552

Kelling JA, Erickson CR, Pin J, Pin PG. Anatomical dissection of the dorsal nerve of the clitoris. Aesthet Surg J. 2020;40(5):541-547. doi:10.1093/asj/sjz330

Hamori CA. Aesthetic surgery of the female genitalia: labiaplasty and beyond. Plast Reconstr Surg. 2014;134(4):661-673. doi:10.1097/PRS.0000000000000516

Question 42

A 58-year-old postmenopausal woman presents to her gynecologist with complaints of vaginal dryness, dyspareunia, and irritation. She has tried topical estrogen therapy but is concerned about the long-term risks of hormonal treatments. She inquires about fractional carbon dioxide (CO₂) laser therapy as a potential alternative. Based on the current evidence, which of the following is the most accurate statement regarding fractional CO₂ laser therapy for postmenopausal vaginal symptoms?

A. Fractional CO₂ laser therapy significantly improves symptom severity and quality of life compared to sham treatment.
B. Fractional CO₂ laser therapy demonstrates significant histological improvements in vaginal tissue compared to sham treatment.
C. Fractional CO₂ laser therapy shows no statistically significant difference in symptom severity, quality of life, or histological outcomes compared to sham treatment.
D. Fractional CO₂ laser therapy is associated with a higher risk of adverse events compared to sham treatment.
E. Fractional CO₂ laser therapy is the first-line treatment for postmenopausal vaginal symptoms, surpassing hormonal therapies in efficacy.

Answer 42

The correct answer is option C.

While the use of lasers for postmenopausal symptoms has increased, there have been few studies showing their effectiveness. A double-blind, randomized, sham-controlled trial of fractional carbon dioxide laser failed to show significant differences between laser and sham control in symptom severity, quality of life scores, or in histological comparisons through 12 months. As demand for nonsurgical vaginal procedures grows, and as patients look for alternatives to long-term hormonal treatments, it is important to accurately represent the overall efficacy of the procedures. Many studies of laser treatment for vaginal symptoms have been plagued by poor methodology and inadequate controls for the placebo effect. The randomized, sham-controlled trial published in JAMA did not demonstrate a statistically significant difference in adverse events between the laser and sham treatments, but it is always important to advise patients of the risks of laser treatment.

Li FG, Maheux-Lacroix S, Deans R, et al. Effect of fractional carbon dioxide laser vs sham treatment on symptom severity in women with postmenopausal vaginal symptoms: a randomized clinical trial. JAMA. 2021;326(14):1381-1389. doi:10.1001/jama.2021.14892

Preminger BA, Kurtzman JS, Dayan E. A systematic review of nonsurgical vulvovaginal restoration devices: an evidence-based examination of safety and efficacy. Plast Reconstr Surg. 2020;146(5):552e-564e. doi:10.1097/PRS.0000000000007236