GU Recon/Trans/Aesthetic 16-22, 24 Flashcards
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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)
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
