Refinement Procedures for Clitorolabiaplasty in Male-to-Female Gender-Affirmation Surgery: More than an Aesthetic Procedure

Mauricio Raigosa MD; Stefano Avvedimento MD; Jordi Descarrega MD; Marta Yuste MD; Juan Cruz-Gimeno MD, PhD; Joan Fontdevila MD, PhD

FIRST PUBLISHED: September 2, 2020 – The Journal of Sexual Medicine

DOI: https://doi.org/10.1016/j.jsxm.2020.08.006

Introduction

Over the years, surgical techniques for male-to-female gender-affirmation surgery (MtF-GAS) have improved, and aesthetic outcomes have become more important to both surgeons and patients. However, clitorolabiaplasty remains challenging.

This retrospective study discusses a technical refinement that adds the creation of a clitoral hood and labia minora to one institution’s clitoroplasty technique. Patients underwent surgery between August 2008 and September 2009 and had follow up data for at least six months.

Technical Approach

The surgery was described as follows:

Our feminizing genitoplasty technique has been described previously.4,5 Orchiectomy, penile disassembly, and creation of the neovaginal cavity were performed similarly in all patients. The main variation in the present study includes the creation of the labia minora and clitoral hood in more recent cases (from September 2017). We implemented specific changes in our technical approach in an attempt to obtain a more natural appearance of the external vulva with well-defined labia minora and adequate clitoral hooding, improving the final patient outcome.

A W incision is made on the dorsal edge of the gland, and 2 triangular flaps are created. The foreskin is left attached to the glandular flaps and is incised ventrally to create 2 symmetrical rectangular flaps. Eventually, the 2 triangular flaps (forming the neoclitoris) and the 2 rectangular flaps (forming the labia minora and the clitoral hood) are detached from the rest of the glans and urethra. Care must be taken to preserve the common neurovascular pedicle that encompasses the deep dorsal vein in the middle surrounded by the dorsal artery and the dorsal nerve on each side. Dorsally, Buck’s fascia is mobilized off the tunica albuginea using blunt dissection. Laterally, the flap is maintained as wide as possible by incising Buck’s fascia at the 10 o’clock and 2 o’clock positions. Dissection proceeds proximally along the entire penile shaft to the pubic symphysis. Once completed, the bundle is folded up to allow proper positioning of the neoclitoris. The neoclitoris is made by suturing together the 2 triangular flaps with an absorbable suture to recreate a conical shape. The rectangular preputial flaps are transposed inferiorly by embracing the neoclitoris to reconstruct in continuity the clitoral hood and the labia minora. The medial edges are then sutured to the dorsal urethral flap and to the segment of the neourethra. This procedure defines accurately the vestibulum, between the base of the neoclitoris superiorly, the urethral neomeatus inferiorly, and the labia minora laterally. To get a natural shape and outline a fold between the 2 labia, the lateral edges are sutured to the deep pelvic fascia adjacent to the labia majora.

 Results

Data was obtained for 167 patients who had penile inversion feminizing genitoplasty. Group A (64 patients, mean age 35.6 years) had labia minora and clitoral hood creation. Group B (103 patients, mean age 33.3 years) did not.

Early and delayed complications were reported as follows:

Forty-two secondary surgeries were performed in 41 patients:

Twenty-four patients underwent 28 types of aesthetic refinements:

Discussion

Because aesthetics are important to patients’ well-being, technical refinements of MtF-GAS “are essential in surgical planning,” and creating the labia minora and clitoral hood in one step is “safe and viable” for these patients.

One disadvantage to the approach is a smaller amount of penile skin to line the neovagina, as the labia minora is created from part of the prepuce attached to the glans penis. Scrotal skin grafts may remedy this situation.

Complications

The complications rate for MtF-GAS is “disappointingly high,” with meatal stenosis being most common issue (rates ranging from 1% to 40%).

Among the patients in this study, urethral stricture incidence was as low as 1.5% due to aesthetic refinements.

Bleeding is typically common in MtF-GAS. In the current study, 40 patients experienced hemorrhages around the urethra and labia. With the modified technique, postoperative bleeding significantly decreased.

Diazepam (10 mg) was used in the early postoperative period to reduce sleep-related nocturnal erections which “are implicated in the postoperative bleeding of the urethral stump.” Postoperative Surgicel and tranexamic acid might be other options.

Wound incidence in Group A was “unexpectedly high” compared to Group B. This result could be due to improved reporting accuracy or the “higher complexity of surgical technique.”

Study Limitations

Several limitations were acknowledged, including the following examples:

• Variables like surgical experience, workload, and learning curve could not be assessed. More experienced surgeons could have better outcomes.
• Standardized patient-reported outcomes were not used.
• There was no specific test used to assess the tactile and erogenous sensitivity of the reconstructed clitoris.

Conclusions

Incorporating the creation of the labia minora in one step is a safe and viable option in patients undergoing MtF-GAS. Technical refinements in neoclitorolabiaplasty are associated with lower incidence of urethral stenosis and bleeding without an increased risk of major complications. Future research is needed to delineate the relation between aesthetics improvements and patient-reported outcomes. Therefore, data standardization is an important prerequisite to allow a better understanding of the effectiveness and outcomes of different techniques.