Journal of Plastic, Reconstructive & Aesthetic Surgery
Volume 62, Issue 3 , Pages 292-293, March 2009

Plastic surgery of the genital area

Department of Plastic and Reconstructive Surgery, Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands

Article Outline

 

That this issue of JPRAS includes no less than 11 contributions on plastic surgery of the genital area in general and gender-confirming surgery in particular,1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 once again reflects the leading position of plastic surgeons in the development of these fields of interest. Our interest in the functional and psychological improvement of the genital area was obvious when the first volumes of major international plastic surgery journals were being published12, 13, 14, 15, 16, 17 and it has been given ample attention during our major international congresses. Because plastic surgery necessarily has a creative and innovating character this interest is mostly presented, as it is again in this issue of the JPRAS, as new or improved surgical techniques.1, 2, 3, 4, 5, 6 Once developed and introduced by plastic surgeons, such techniques are likely to be included in the surgical armamentarium of other specialists also. Still, merely developing or improving surgical options proves no longer to suffice. Increasingly, we are required to present a rationale for our deeds in light of both the financial limitations put forward by the health care insurance systems, and a responsibility to provide transparent information to commissioners and purchasers of health care about the benefits and disadvantages of surgery.8, 9 We have the moral duty to provide not just our best of care, but the best of care to our patients.

Twenty-five years ago, Milton T Edgerton set the standards to provide the best of gender-confirming care.18 These include: (1) a diagnostic selection process that will allow uniform screening of the many patients with gender dysphoria for those who may not be reasonably helped by gender-confirming surgery; (2) high-quality operations that give uniformly good aesthetic and functional results with reasonable cost and risk; and (3) careful postoperative follow-up of unselected groups of patients over a 10- to 20-year period.18

To address Edgerton's first standard, plastic surgeons necessarily lean on the expertise of specialised behaviour scientists,19 and it has been agreed internationally that gender-confirming surgery should be provided only by dedicated specialists working in well-organised, multi-disciplinary teams.20 All current evidence presented by behaviour scientists supports the opinion that gender-confirming surgery is beneficial for well-selected patients and may be cost-beneficial for society.20, 21, 22, 23 Time and again, it has been proven that for the genuinely transsexual, “cross-dressing is an insufficient help, as aspirin for a brain tumour headache would be.”24

Outcome studies such as those presented in this issue by Kim et al.7 and Nelson et al.8 and most of the work reviewed by Sutcliffe et al.9 and Selvaggi and Monstrey,10 support the conclusion that gender-confirming surgery provided by dedicated surgeons is of high quality and assures a favourable short-term aesthetic and functional outcome with restricted risk. Still, plastic surgeons tend to focus on reporting the innovations and refinements of technique to their peers in order to efficiently further the surgical treatment of as many patients as possible. These reports, by necessity, are concise and technically difficult to interpret for outsiders. This, indeed, limits the ability of commissioners of health care to identify studies that are relevant to them. To each of our patients we, obviously, have to explain the pros and cons of multiple gender-confirming surgical techniques so that he or she will be able to make a well-informed, individualised choice of treatment. The standard of care requires surgeons who are skilled in only a single technique, to so inform their patients and refer to another surgeon those who do not want, or are unsuitable for, this technique.20

So far, we failed to adequately address Edgerton's third standard even though long-term follow-up studies have increasingly been presented over the last years. Still, the level of evidence of these studies, in general, is poor as holds true for most of the plastic surgical literature and,25, 26 indeed, most of the surgical literature.26, 27 Notwithstanding the methodological and conceptual flaws of the evaluation of gender-confirming surgery presented in this issue,28 its message is clear: we are in need of evidence of sufficient level to support the long-term benefits of these surgical interventions.9

Given that the life-long hormonal treatment of transsexuals is to be provided or, at least, supervised by gender teams,20 this demand for long-term proof of adequate level is not irrational. It should be fairly easy to prospectively assess the long-term outcome of surgery as long as patients are being treated by other specialists of these multidisciplinary teams. Such assessment should not only address the anatomical or aesthetic outcome of surgery but also its functional and psycho-sociological implications. Only with such robust outcome data can we be expected to successfully counter the misconceptions or misinterpretations raised by outsiders regarding the magnitude of benefit and harm of our deeds.

Back to Article Outline

Conflict of interest/funding 

None

Back to Article Outline

References 

  1. Descamps MJ, Hayes PM, Hudson DA. Phalloplasty in complete aphallia: pedicled anterolateral thigh flap. J Plast Reconstr Aesthet Surg. 2009;62:e51–e54
  2. Ma Y, Qin R, Bi H, et al. The use of peritoneal tissue mobilised with a novel laparoscopic technique to reconstruct a neovagina. J Plast Reconstr Aesthet Surg. 2009;62:326–330
  3. Warren AG, Peled ZM, Borud LJ. Surgical correction of a buried penis focusing on the mons as an anatomic unit. J Plast Reconstr Aesthet Surg. 2009;62:388–392
  4. Majdak-Paredes EJ, Shafighi M, Fatah F. Unilateral hypoplastic breast in a male-to-female transsexual with Poland syndrome after gender reassignment - reconstructive considerations. J Plast Reconstr Aesthet Surg. 2009;62:398–401
  5. Dessy LA, Mazzocchi M, Buccheri EM, et al. The ring stitches, a useful method to manage vaginal stent in male-to-female transsexuals. J Plast Reconstr Aesthet Surg. 2009;62:409–410
  6. Lin CT, Chen LW. Using a free thoracodorsal artery perforator flap for phallic reconstruction - A report of surgical technique. J Plast Reconstr Aesthet Surg. 2009;62:402–408
  7. Kim SK, Lee KC, Kwon YS, et al. Phalloplasty using radial forearm osteocutaneous free flaps in female-to-male transsexuals. J Plast Reconstr Aesthet Surg. 2009;62:309–317
  8. Nelson L, Whallett EJ, McGregor JC. Transgender patient satisfaction following reduction mammaplasty. J Plast Reconstr Aesthet Surg. 2009;62:331–334
  9. Sutcliffe PA, Dixon S, Akehurst RL, et al. Evaluation of surgical procedures for sex reassignment: a systematic review. J Plast Reconstr Aesthet Surg. 2009;62:294–306
  10. Selvaggi G, Monstrey S. Commentary: Evaluation of surgical procedure for sex reassignment: a systematic review. J Plast Reconstr Aesthet Surg. 2009;62:306–307
  11. McGregor JC. Labial surgery - a new phenomenon?. J Plast Reconstr Aesthet Surg. 2009;62:289
  12. Dartigues . De la génitoplastie masculine. Revue Chir Plast. 1931;1:73–76
  13. Robinson DW, Stephenson KL, Padgett EC. Early coverage of the penis, scrotum and urethra. Plast Reconstr Surg. 1946;1:58–68
  14. Gillies H, Harrison RJ. Congenital absence of the penis. Br J Plast Surg. 1948;1:8–28
  15. McIndoe A. Deformities of the male urethra. Br J Plast Surg. 1948;1:29–47
  16. Wilflingseder P. Construction of the vagina by means of an intestinal mucosa-muscularis-graft. A new method in the treatment of aplasia or stricture of the vagina. Chirurgia Plastica. 1971;1:15–24
  17. Simon BE. Transsexual surgery. Ann Plast Surg. 1978;1:129–130
  18. Edgerton MT. The role of surgery in treatment of transsexualism. Ann Plast Surg. 1984;13:473–476
  19. Hage JJ, Karim RB. Ought GIDNOS get nought? Treatment options for nontranssexual gender dysphoria (Editorial). Plast Reconstr Surg. 2000;105:1222–1227
  20. Meyer WM, Bockting WO, Cohen-Kettenis P, et al. The Harry Benjamin International Gender Dysphoria Association's Standards of Care for Gender Identity Disorders, Sixth Version. J Psychol Human Sexual. 2001;13:1–30
  21. Kuiper B, Cohen-Kettenis P. Sex reassignment surgery: a study of 141 Dutch transsexuals. Arch Sex Behav. 1988;17:439–457
  22. Pfäfflin F, Junge A. Sex reassignment. Thirty years of International follow-up studies after sex reassignment surgery: a comprehensive review, 1961-1991. Düsseldorf: Symposion Publishing; 1998;Available from: http://www.symposion.com/ijt/pfaefflin/1000.htm[assessed 1.1.09]
  23. Smith YL, Van Goozen SH, Kuiper AJ, et al. Sex reassignment: outcomes and predictors of treatment for adolescent and adult transsexuals. Psychol Med. 2005;35:89–99
  24. Benjamin H. Transvestitism, transsexualism, and homosexuality. In: The transsexual phenomenon. New York: Julian Press; 1966;p. 11–28
  25. Offer GJ, Perks AG. In search of evidence-based plastic surgery: the problems faced by the specialty. Br J Plast Surg. 2000;53:427–433
  26. Loiselle F, Mahabir RC, Harrop AR. Levels of evidence in plastic surgery research over 20 years. Plast Reconstr Surg. 2008;121:207e–211e
  27. Brooke BS, Nathan H, Pawlik TM. Trends in the quality of highly cited surgical research over the past 20 years. Ann Surg. 2009;249:162–167
  28. Hage JJ. Commentary: Evaluation of surgical procedures for sex reassignment: a systematic review. J Plast Reconstr Aesthet Surg. 2009;62:307–308

    Chief Editors comment: The Editorial which appears above by J. Joris Hage was written before the final issue was compiled and there are actually twenty-three articles related to genital and gender related surgery in the final issue.

PII: S1748-6815(09)00028-X

doi:10.1016/j.bjps.2009.01.005

Journal of Plastic, Reconstructive & Aesthetic Surgery
Volume 62, Issue 3 , Pages 292-293, March 2009

Article Tools