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1、Sex reassignment surgery,KEY WORD:Sex reassignment/reconstruction surgerygender identity disorderGenitalGenitoplastyDysphoria,WHAT IS THE Sex reassignment surgery(SRS)?It also can be called gender reassignment surgery,or sex-change operation It is a term for the surgical procedures by which a person
2、s physical appearance and function of their existing sexual characteristics are altered to resemble that of the other sex.It is part of a treatment for gender identity disorder/gender dysphoria in transsexual and transgender people.It may also be performed on intersex people,often in infancy.Other t
3、erms for SRS include gender reassignment surgery,sex reconstruction surgery,genital reconstruction surgery,gender confirmation surgery,and more recently sex affirmation surgery.The commonly used terms sex change or sex change operation are considered factually inaccurate.The terms feminizing genitop
4、lasty and masculinizing genitoplasty are used medically.The best known of these surgeries are those that reshape the genitals,which are also known as genital reassignment surgery or genital reconstruction surgery(GRS).However,the meaning of sex reassignment surgery has been clarified by the medical
5、subspecialty organization,the World Professional Association for Transgender Health(WPATH),to include any of a larger number of surgical procedures performed as part of a medical treatment for gender dysphoria.transsexualism or gender identity disorder”,WHAT DOES IT INCLUDE?According to WPATH,medica
6、lly necessary sex reassignment surgeries include complete hysterectomy,bilateral mastectomy,chest reconstruction or augmentation including breast prostheses if necessary,genital reconstruction(by various techniques which must be appropriate to each patient and certain facial plastic reconstruction.I
7、n addition,other non-surgical procedures are also considered medically necessary treatments by WPATH,including facial electrolysis.The array of medically necessary surgeries differs for transwomen(male to female)rather than transmen(female to male).For transwomen,genital reconstruction usually invol
8、ves the surgical construction of a vagina,whereas in the case of transmen,genital reconstruction may involve either construction of a penis or metoidioplasty/construction of a penis.For some transwomen,facial feminization surgery and breast augmentation are also medically necessary components of the
9、ir surgical treatment.For transmen these may include mastectomy(removal of the female breasts)and chest reconstruction(the shaping of a male-contoured chest),or hysterectomy and bilateral salpingo-oophorectomy.,Feminizing Surgery Male to Female(MTF)Sex Reassignment Surgery,Surgical procedures Augmen
10、tation mammaplasty(breast augmentation)MTF genital reconstruction Facial feminizing surgery Voice pitch-elevating surgery Other(lipoplasty,removal of rib,injection of free silicone),Augmentation mammaplasty,It will usually be delayed until after hormonal therapy has been under taken for a period of
11、18 months to allow time for maximal hormonal breast development.Compared to non-transgender women,the breast developement of the MTF patient is often undeveloped and tight and there may be less lipomatous tissue.A staged approach involving initial tissue expansion(as in reconstruction following mast
12、ectomy)is sometimes used for optimal results.there is no clinical consensus on the best way to promote nipple and breast development in transgender Results vary,but in general,the nipple-areola complex appears under-developed and lateralized even after years of hormone treatment.Even after two years
13、 of feminizing hormones MTF breast development typically corresponds to the conical shape seen in young adolescents,without the ptosis normally seen as a result of aging.The patient should be made aware that implants cannot perfectly imitate adult breasts.In particular,the age-related changes seen i
14、n non-transgender women and cleavage between the breasts is very difficult to createThe decision of whether to augment or not is very similar for a TS women as for any other woman-a complex one with many tradeoffs of appearance vs sensation vs risks of complications.,MTF genital reconstruction,1.Vag
15、inoplasty The term vaginoplasty includes several procedures which transform the male external genitalia into female genitalia.The goals of vaginoplasty includecreation of a sensate and aesthetically acceptable vulva(including clitoris,labia minora and majora,and vaginal introitus)shortening of the u
16、rethra,with creation of a urethral opening that allows a downward urinary stream creation of a stable and sensate neovagina with adequate dimensions for penetrative sexual intercourse,ideally lined with moist,elastic,hairless epithelium elimination of erectile tissue(to avoid narrowing of the introi
17、tus and protrusion of the urethral meatus/clitoris during sexual arousal)preservation of orgasmic capability,Readiness criteria1)Able to give informed consent 2)On hormones for 12 months(if needing and medically able to take hormones)3)At least 1 year“real life experience”4)Completion of any psychot
18、herapy required by the mental health professional5)Informed of cost,hospitalization,complications,aftercare,and surgeon,The penile inversion technique is most commonly used to create the neovaginaThe majority of skin from the shaft of the penis is inverted and used to line the inner walls of the neo
19、-vagina.In some cases,extra skin is required to line the inner vagina.From the patients lower abdomen,or scrotal skin grafts may be used.Use of a segment of the colon(rectosigmoid pedicled transplant)is the third choice A portion of the horizontal part of the urethra is preserved and used to fashion
20、 the female urethra and surrounding tissue.The neovagina is positioned posterior to the prostate(which is untouched).Labia minora are constructed from prepuce or penile skinLabia majora are constructed from scrotal skin.A small portion of the glans is preserved by maintaining attachments to its nerv
21、e and blood supply.Revisions may be performed after the vaginoplasty to refine the appearance of the clitoris,labia,or the superior aspect of the labia majora(anterior commisure).,1、Dr.Meltzer将麻醉了的病人安置好，準备手术。病人的大腿下部到小腿都包裹了一连串的压力袜，以便避免血液在腿部凝结成块。,2、要切除的阴囊表皮已经用外科紫色笔标记出来。请注意，环绕阴囊的那片约略圆形区域的皮肤稍后将作为阴道植皮之用。
22、底部那一小块叁角形的盖皮未来将会併入阴部的开口，以避免在这个部位形成圆形的疤痕。,4、手术开始。Dr.Meltzer先切除阴囊表皮，留作稍后阴道植皮之用。这裡使用的是一把黄柄的电动外科器具，在切除组织的同时还可以封凝血管。,3、先用消毒皂清洗病人的生殖器，然后盖上消毒布帷。图左的这个装置是用来稳固环状牵引器，以便稍后用来帮助製造阴道的甬道(见图11)。请注意图中固定在皮肤上的外科透明布帷，布帷上设有乳胶套，外科医生在製造阴道时可以透过这个乳胶套将手指插入直肠以维持稳定，而不至于被肛门的污物污染手套或是手术区域。后来发现，Dr.Meltzer在这次的手术中并不需要用到那个步骤。,6、阴囊皮去除后
23、，睪丸就可以被独立出来，然后移除。图中当Dr.Meltzer在施行切除手术之时，他的助理正在将右睪丸以及韧带部份往上拉。,5、这就是切下的阴囊表皮。后来再看到它时，样子会有些不同(见图9)。,7、接着Dr.Meltzer将阴茎表皮与其下的勃起组织分割。他先围绕着龟头周围切割，然后顺势逐步切割剥离阴茎的表皮。图中Dr.Meltzer用左手的拇指和食指握住龟头，一位助理则以两个皮肤勾来保持阴茎皮肤的张力。,8、这是阴茎表皮剥离后的结果。图中一位助理拉住已经被剥离的阴茎表皮，预备外翻，以作为阴道的内衬。在图的下方，阴茎残余的勃起组织也已裹上了纱布以控制流血。,10、在这裡，套着阴囊植皮的皮下注射器套
24、已经放进了阴茎表皮做成的管道内，植皮正在被缝进阴茎表皮管道的边缘。这样一来就拉长了阴茎表皮管道，稍后可以用来当作阴道的内衬。,9、还记得我们在图5看到的那块阴囊表皮?Dr.Meltzer进行手术的同时，他的助理便将这块阴囊表皮刮薄，以一支大型皮下注射器套作为支撑，将切下的阴囊表皮缝成一端封闭的管状。在下一张图中，这整个成品都会被放进由那个外翻的阴茎表皮缝成的管道内，以便把这个管状植皮缝到适当的位置。,12、当阴道的甬道做好后，Dr.Meltzer切开阴茎根部的海绵组织，以便打开尿道，他将一根Foley导管穿进尿道口，放进膀胱内。在接下来手术创造新的尿道和尿道口时，这些周围组织都要重新修整过。,
25、11、接下来就要製造阴道了。如图，Dr.Meltzer用食指测试开口处的深度。图中显示Dr.Meltzer使用两种特殊技巧来进行这个复杂的切割手术。首先，他将Lowsley前列腺牵引器插入阴茎，以便在进行切割时方便操控前列腺，图片上方还可以在Dr.Meltzer的右手中看到牵引器的T形手把。其次，Dr.Meltzer用了Bookwalter小儿科环形牵引器系统来保持阴道张开，以利整个切割手术进行，环底附着的两个牵引器则维持了阴道向下和侧面的压力。,13、Dr.Meltzer现在开始从左右两侧切入，将阴茎周围的勃起组织剥除。最后将只留下龟头以及一片薄薄的、背侧有血管和神经的肉茎。,14、现在龟头
26、只靠着一条像缎带一般的肉茎来和身体连结，但是被小心保存在这条肉茎内的血管和神经将继续活络龟头的组织和感觉。,16、如图，下腹皮肤已经和其下的组织分开，以一个牵引器往上拉到肚脐的高度。将下腹皮肤拉开是为了让(图中被牵引器挡住的)阴茎皮可以被向下拉到足以进入阴道的程度。另一方面，连接阴蒂的那条肉茎也已经被反摺，好把阴蒂缝到应有的位置上。,15、Dr.Meltzer开始将龟头组织塑成阴蒂，他先将龟头的下半部切除，然后将切口的边缘缝合，製造了一个大小适当的阴蒂，相连的肉茎则将提供阴蒂所需的神经和血液。,18、经过一些修整，Dr.Meltzer将阴道植皮缝进会阴的皮肤内，固定好。,17、现在可以将植皮放
27、进阴道了。Dr.Meltzer将一支弯嘴牵引器插入阴茎阴囊合成的植皮管道，引导这个管道顺利的进入体腔。Dr.Meltzer的右手握住牵引器，左手则在阴道的开口处。,19、Dr.Meltzer在新阴户的皮肤上开一道口子，阴蒂就放在这裡。我们在这张图片中可以看到缝好后的样子。第二个切口较低，也可以在这裡看到，这是新的尿道口。阴道内有一个加了重量的牵引器。,20、现在尿道的组织已经修整好，并且从会阴上较低的那个开口拉出来，开闢成一个新的泌尿管道。尿道上的Foley导管就显示了尿道的开口，位置非常接近阴道的开口处。那裡仍然有很多剩余的阴囊皮肤必须被修整，以创造大阴唇。,22、在两片阴唇都修整出形状而且
28、也缝好之后，Dr.Meltzer插入一个扩张器到阴道内做为阴道塑形的準备。,21、图中Dr.Meltzer已经修整好了右边阴唇的皮肤(也就是病患的左边)，开始缝合切口。从阴唇上端延伸下来一条排除液体的管子，这条管子在术后的几天内都会排出这个区域累积的淤血或体液。,24、现在阴唇已经几乎完全的缝在一起了，排除多余淤血体液的管子和Foley导管从顶端冒出来。除了最后的包扎之外，整个手术已经完成了。,23、这张照片中，阴道填入了纱布，图中露出的一点点白纱布就标示了阴道的开口。Dr.Meltzer现在开始暂时缝合阴唇，这种暂时的缝合可以施压阴唇，以减少流血和肿胀，数天后再拆除。,2、Facial fe
29、minizing surgery Drawing on techniques from soft tissue plastic surgery,maxillofacial surgery,and reconstructive surgery,facial feminizing surgery techniques were pioneered by maxillofacial surgeon Douglas Ousterhout in the USA60-62 and are now widely available.Facial feminizing surgery involves the
30、 use of one or more procedures to reduce stereotypically masculine features and impart more conventionally feminine features to the patients head and neck region.Facial feminizing surgery procedures include,but are not limited to:removal of supra-orbital bossing(“brow bossing”)and orbital rim contou
31、ring,brow elevation,rhinoplasty,ear pinning,augmentation of the lip vermilion area,cheek augmentation,widening of the zygomatic complex,chin/jaw reduction,clockwise rotation of the bimaxillary complex,and reduction laryngochondroplasty(also known as“tracheal shave”or“Adams apple reduction”).,Voice p
32、itch-elevating surgery,Surgical alteration of the laryngeal framework and/or vocal cords is sought by some transsexual women who have not been able to sufficiently elevate pitch through speech therapy alone.Techniques,risks/complications,and outcome data are discussed in Transgender Speech Feminization/Masculinization:Suggested Guidelines for BC Clinicians.,THANK FOR YOUR ATTENTION!,
