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To date, many techniques have been reported for vaginoplasty in male-to-female trans-sexual (MTFTS) patients, such as the use of a rectum transfer, a penile-scrotal flap and a reversed penile flap. However, none of these procedures is without its disadvantages. We developed a newly kind of flap for vaginoplasty, the M-shaped perineo-scrotal flap (M-shaped flap), using skin from both sides of the scrotum, shorn of hair by preoperative laser treatment. We applied this new type of flap in 7 MTFTS patients between January 2006 and January 2007. None of the flaps developed necrosis, and the patients could engage in sexual activity within 3 months of the operation. The M-shaped flap has numerous advantages: it can be elevated safely while retaining good vascularity, it provides for the construction of a sufficient deep vagina without a skin graft, the size of the flap is not influenced entirely by the length of the penis, and it utilizes skin from both sides of the scrotal area, which is usually excised.

The first operative procedure in sex reassignment surgery (SRS) for female-to-male transsexuals (FTMTS) is mastectomy. This procedure includes the removal of mammary tissue, removal of excess skin, and reduction and proper repositioning of the nipple and areola complex. We have performed mastectomies in over 120 patients since January 2001 and want to describe the operative procedures we have developed. We classified our patients into 3 groups according to the patient's breast volume and the degree of ptosis, and we selected the operative procedure that was suitable for each group. At present all costs for SRS are assumed by the patient in Japan. If the FTMTS patient undergoes the entire series of SRS operations, he has to pay more than 3,000,000 yen. Thus the surgeon should select the proper operative procedure so that the patient can avoid unnecessary additional operations. We describe herein the techniques and the strategy for performing mastectomy in FTMTS.

Between January 2001 and December 2007, we performed vaginoplasty as sex reassignment surgery in a total of 14 male-to-female transsexual (MTFTS) patients [1]. Several complications occurred such as partial flap necrosis, rectovaginal fistula formation and hypersensitivity of the neoclitoris. Just after the operation, some patients feel that their penises still exist, but by several weeks postoperatively, this sensation has disappeared. Herein we report a case of MTFTS in whom the sensation of a phantom erectile penis persisted for much longer.

We treated 2 different types of intersexual patients who underwent a vaginoplasty with the pudendal-thigh flap. One was a female with testicular feminization syndrome for whom we reconstructed the total vagina with a pudendal-thigh flap, and the other was a female with an adrenogenital syndrome for whom we enlarged the introitus of the vagina with the same approach. There were no complications such as a flap necrosis. In addition, there was no stricture of the neo-vagina and no urinary problem.