Hypospadiac genital tubercle (GT)

ABSTRACTIntroductionAfter the diagnosis of transsexualism is confirmed therapy commences with psychotherapeutic preparation for the conversion, and after conversion, long-term patient rehabilitation is maintained for at least two years. The indication for surgery is chronic discomfort caused by discord with the patient's natural gender, intense dislike of developing secondary sex characteristics and the onset of puberty. The surgical conversion of transsexuals is the main step in the complex care of these problematic patients (1). This surgery was first described by Benjamin H, using a flap of inverted penile skin (2) and is considered the gold standard since then. Male-to-female transsexual surgical techniques are well defined and give good cosmetic and functional results. Sex reassignment surgery promotes the improvement of psychological aspects and social relationships as shown in the World Health Organization Quality of Life Assessment applied in the patients submitted to this procedure (3). Techniques include the creation of a normal appearing female introitus, a vaginoplasty allowing sexual intercourse and the capability of clitoral orgasm (4). Various methods for neovaginoplasty have been described and can be classified into five categories, i.e. pedicled intestinal transplants, penile skin grafts, penile skin flaps, non-genital skin flaps and non-genital skin grafts (5). In our Hospital, we use penile and scrotal skin flaps. Until now, 174 procedures have been performed by our team using this technique with high rates of satisfaction (3).Patients and methodsWe present a step-by-step male to female transsexual surgery.ConclusionSurgical gender reassignment of male transsexuals resulted in replicas of female genitalia which enabled coitus with orgasm (1). With this video we show step by step that a surgery using penile skin flaps is able to be performed with good cosmetic results.

To report experience of a new surgical technique in male-to-female transsexual patients, the complications, and the functional and psychosocial long-term results. From April 1995 to July 2000, 66 male patients underwent gender-transforming surgery at our institution and were registered prospectively. The operation should result in a normal appearing introitus, a vaginoplasty allowing for sexual intercourse and a sensitive clitoris. This was achieved by preserving the neurovascular bundle. The glans was transformed into a clitoris, the phallic cylinder used as a vagina and labia were formed from the scrotal folds. Major complications during, immediately and some time after surgery occurred in nine of the 66 patients (14%), including severe wound infections in six, a rectal lesion in three, necrosis of the glans in three and necrosis of the distal urethra in one. Minor complications, e.g. meatal stenosis in seven patients, occurred in 24 (36%) of patients. Ten patients with insufficient penile skin had the phallic cylinder augmented with a free-skin mesh graft, but in three of these patients an ileal augmentation was finally constructed because scarring occurred at the suture line between the penile skin and the augmented graft. A long-term follow-up questionnaire about the functional and psychosocial aspects was completed by 31 patients. More than 90% of the patients were satisfied with the cosmetic result and capacity for orgasm; 58% reported having sexual intercourse. Male-to-female surgery can achieve excellent cosmetic and functional results. Although the operative technique is partly standardized, surgery remains challenging because of several possible complications. None of the present patients claimed to regret their decision to undergo gender-transforming surgery.

Plain Language SummarySurgery with digit preservation is the recommended treatment for early forms of nail melanoma (a type of skin cancer that affects the nails). When the melanoma is very thin or limited to the surface of the nail, allowing the wound to heal on its own (known as secondary intention healing or SIH) can be a good alternative to closing the wound after surgery. This method has shown good cosmetic and functional results, fewer complications, and high patient satisfaction. In this study, we evaluated 6 patients who underwent this type of surgery with SIH. We focused on how long it took for their wounds to heal, how much pain they experienced, cosmetic results, finger function, complications, and overall satisfaction. The wounds took around 8.5 weeks to heal completely. Patients reported good functional and cosmetic results. Their quality of life was minimally affected, with high satisfaction scores (9.8 out of 10). Importantly, no recurrences of melanoma or skin discoloration were observed. In conclusion, healing with SIH is a safe and effective option. It also allows flexibility if more tissue needs to be removed later while still providing excellent cosmetic and functional results.

Methods: This prospective observational study was conducted in the Department of Pediatric Surgery, Bangladesh Medical University (BMU), from July 2019 to June 2020. Seventy patients aged 1–14 years with anterior or mid-penile hypospadias who underwent surgical repair were included. Cosmetic outcomes were assessed preoperatively and postoperatively at 1, 3, and 6 months using the HOPE score. Statistical analysis was performed using SPSS version 26.0. Results: The mean total HOPE score increased significantly from 37.50 ± 9.05 preoperatively to 48.67 ± 3.41 at six months postoperatively. Significant improvement was observed in all evaluated domains, including meatal position, meatal shape, glans shape, penile skin, and penile axis. The cosmetic outcome remained stable from one month through six months postoperatively. Conclusion: The HOPE score is a reliable and objective tool for assessing cosmetic outcomes after hypospadias repair. Significant postoperative improvement in HOPE scores reflects successful surgical correction and satisfactory cosmetic results. Journal of Paediatric Surgeons of Bangladesh (2022) Vol. 13 (1 & 2): 3-7

Intraoperatively fabricated polymethylmethacrylate (PMMA) implants based on computer-designed moulds were used to improve cosmetic results after hard tissue replacement. To assess the implant's cosmetic and functional results we performed both subjective and objective assessments. This retrospective analysis was performed using a cohort of 28 patients who received PMMA implants between February 2009 and March 2012. The cosmetic and functional results were assessed using a patient questionnaire. Furthermore an objective volumetric subtraction score (0-100) was applied and implant thickness, as well as gaps and tiers, were measured. Patients mainly judged their cosmetic result as "good". Two of the 28 patients found their cosmetic result unfavourable. The functional result and stability was mainly judged to be good. Measurements of implant thickness showed a very high correlation with the thickness of the contralateral bone. Volumetric subtraction led to a median quality of 80 on a scale from 0 to 100. Median gaps around the margins of the implant were 1.5 mm parietally, 1.7 mm frontally and 3.5 mm fronto-orbitally, and median tiers were 1.2 mm, 0 mm and 0 mm respectively. The overall rate of surgical revisions was 10.7 % (three patients). Two patients suffered from wound healing disturbances (7.1 %). The overall complication rate was comparable to other reports in the literature. Implantation of intraoperatively fabricated patient-specific moulded implants is a cost-effective and safe technique leading to good clinical results with a low complication rate.

Animal models are commonly used to study spinal cord injuries (SCI). These models aim to better understand the traumatic behaviour of the spinal cord in vivo. However, experimental SCI models usually simulate a posterior contusion of the spinal cord on small animals, which do not reproduce completely the SCI mechanisms in humans. The objectives of the study are: 1) to develop an experimental anterior contusion of the spinal cord on porcine models, and 2) to compare biomechanical differences between ventral and dorsal approaches. A total of 6 specimens were tested in vivo with a drop weight bench test. Impacts were produced at T10 with 5mm diameter impactor of 50g and dropped from a height of 100mm. Compression time was set to 5min for 4 specimens (2 ventral, 2 dorsal) and 60min for 1 ventral and 1 dorsal. The outcome measures were the compression displacement, blood pressure, heart rate and macroscopic inspection of the spinal cord. This is the first study proposing an animal model of anterior SCI. Preliminary results suggest that there is a biomechanical difference between ventral and dorsal contusion approaches. A new bench test especially designed for ventral contusion will allow additional tests analyzing more variables, such as the motor evoked potentials and arterial blood flow.

Objective To ameliorate the clinical decision-making process when debating between a ventral or dorsal cervical approach by elucidating whether post-operative dysphagia be regarded as a complication or a transient side effect. Methods A literature review of studies comparing complication rates following ventral and dorsal cervical approaches was performed. A stratified complication rate excluding dysphagia was calculated and discussed. A retrospective cohort of patients operated for degenerative cervical myelopathy in a single institution comprising 665 patients was utilized to analyze complication rates using a uniform definition for dysphagia. Results Both the ventral and the dorsal approach groups exhibited comparable neurological improvement rates. Since transient dysphagia was not considered a complication, the dorsal approach was associated with higher level of overall complications. Conclusions and relevance Inconsistencies in the definition of dysphagia following ventral cervical surgery impedes the interpretation of trials comparing dorsal and ventral complication rates. A uniform definition for complications and side effects may enhance the validity of medical trials.

Dear Editors, We read with attention the study entitled “Long-term follow-up comparison of two different bi-layer dermal substitutes in tissue regeneration: Clinical outcomes and histological findings,” and we want to emphasise that our clinical experience with the two devices Integra and Nevelia is different. Dermal substitutes are becoming more essential in the treatment of acute and chronic wounds. A dermal substitute improves functional and cosmetic results in the long term and outcome. They allow the formation of a new dermis with chemical and elasticity characteristics like normal skin. According to Yannas et al,1, 2 a dermal substitute with regenerative activity must have an appropriate pore size, which is critical to the optimal in-growth of patients' fibroblasts and endothelial cells. Yannas et al define this pore size as between 20 and 125 μm. Another important characteristic of a regenerative dermal substitute is the controlled half-time degradation time of 14 ± 7days. Finally, another important feature of a dermal substitute (DS) to create dermis is surface chemistry. For Yannas et al, in DS the ligand densities of myofibroblasts (MFB) should 200 μM α1β1 or α2β1 ligands. This important feature allows these cells to anchor in a better way to the scaffold, and therefore the MFB can create a better dermis pattern.3 Only Integra integra dermal regeneration template (IDRT) has these important features that allow a better interaction between cells and scaffold. Concerning of the scaffold composition, we also want to emphasise that the glycosaminoglycan (GAG) and chondroitin 6 sulfate are important constituents for a regenerative scaffold. Chondroitin 6 sulfate increases the half-life of the scaffold and allows a better interaction between cells and scaffold.4 The degradation rate of scaffolds for wound repair is usually controlled by glutaraldehyde-induced cross-links. This chemical cross-link can lead to an immunogenic response to the scaffold. In the manufacturing process of Integra IDRT, the collagen is cross-linked with GAG and allows for the use of a less quantity of the solvent compared with the scaffolds that are composed only with collagen. Yannas et al show that chondroitin 6 sulfate increases the modulus of resistance and elasticity of the scaffold GAGs Cross-linking and maintaining allows to keep the degradation duration half-time faster compared with the one of scaffold without GAG, that needs more glutaraldehyde, leading to higher foreign response. In this study, the authors make a comparison between Integra and Nevelia in traumatic wounds. The authors observed a difference at 3 years of follow-up measured with MSS, which is a subjective assessment scar scale. First, we want to emphasise that the sample size is limited. Moreover, Integra Dermal Regeneration Template is the only dermal substitute that has a long and significant clinical history in several indications. Several randomised control trials (RCT) show that Integra showed better functional and aesthetic outcomes at long follow-up not only with subjective scar scales but also instrumentally. Lagus et al,5 in a randomised controlled trial, showed that patients reported favourable aesthetic outcomes as measured by the Vancouver Scar Scale. In another randomised clinical trial in paediatric patients, Branski et al6 evaluated the long-term cosmetic and functional results (18-24 months). Also in this study, Integra showed significant improvement in the Hamilton Burn Scar scale. Integra has also other studies that showed its efficacy in terms of functional and cosmetic outcome in burned hands. Among them, Danin7 employed a Cutometer to evaluate the quality of the scars obtained after using Integra Dermal Regeneration Template. When data and elasticity (cutometrical data) were compared for Integra Dermal Regeneration Template-treated burns and normal skin, there were no statistically significant differences between the Integra and normal skin. Another study by Dantzer8 assessed the safety and performance of Integra Dermal Regeneration Template when used to treat deep hand burns and reconstruct scars; there was 100% Integra Dermal Regeneration Template graft take improvement of Vancouver Scar Scale and favourable cosmetic and functional outcomes. After our searches (PubMed, Medline) we noticed that Nevelia has a limited number of studies (only four observational retrospective studies) to show its systematic efficacy in terms of aesthetics and functional outcomes, and in terms of artificial dermis take a percentage that is an important feature of a dermal implant. Integra IDRT has shown in RCT a high take rate even in traumatic wounds.9 Another limitation of this study is that wounds with, exposed tendons or bones, are excluded. One important function of a dermal substitute is the ability to cover avascularised tissue, such as tendons and bones. When we have soft tissue defects overlying exposed tendon, it is important to avoid adhesions, restoration of functionality, and getting good aesthetic outcomes. Shores et al showed that Integra IDRT in the reconstruction of soft tissue with exposed tendons of paratenon in upper and lower extremity allows immediate tendon coverage with good cosmesis and tendon function and a high split-thickness skin graft take rate of 92.5%.10 Yeong et al11 found the same results in the treatment of bone-exposed wounds in burn patients with Integra. In conclusion, Integra has shown the ability to cover poor avascularised structures that allow high split-thickness skin graft take rates. From our experience, a dermal substitute should promote neodermis suitable to be grafted, even in a wound with poor vascularization. Due to the exclusion criteria of this study, we cannot evaluate the efficacy of Nevelia on these wounds. Nicoletti et al in an observational study to treat scalp defects, describe better cosmetic outcomes using Integra comparing with Hyalomatrix and Nevelia.12 An RCT on Integra in chronic wounds17 also showed higher complete healing of wounds. Integra has also several studies on the traum wounds a higher take rate, and the scars outcomes measured with Vancouver scale gave better scores13-15 (Vakerio, Seavey, Weigert). Regarding the histological findings, we also have some concerns. In this study, they claim that Integra collagen was still present after 3 weeks, while Nevelia was completely resorbed. Stern et al16 in their histologic study on 131 patients found the same discovery and identified six phases of repair with Integra. The presence of a scaffold after 3 weeks is a clear sign that the structure of the scaffold is strong. We think that the presence of the scaffold after 3 weeks is an important feature because Integra continues to act as a scaffold during the process of wound healing. Moreover, the presence of Integra collagen means that the chemical cross-link associated with GAGs is a better choice for a regenerative scaffold. In this study, the authors talk about the findings of Agrawal et al. We want to emphasise that according to Agrawal et a's findings, Integra showed a mixed M1/M2 macrophage in histologic samples of Sprague Dawley rats and that this response is associated with a more constructive tissue remodelling response. This is confirmed by the functional and aesthetic outcomes of several studies of Integra that show Integra creates a dermis similar to normal skin. Due to the low clinical and preclinical literature of Nevelia, there is no evidence of macrophage polarisation and tissue remodelling of this device. In our clinical experience with Nevelia, we have had some difficulty to remove the reinforced polyester silicon sheet, because of its tendency to encapsulation. For the clinical outcomes in some cases with Nevelia, there was a rapid degradation of the scaffold. This rapid degradation led to the formation of granulation tissue and led to a contracted scar. In conclusion, considering that most significant literature and clinical use of Integra in several indications (burns, traumatic, chronic wounds, reconstructive surgery) and the aesthetic and functional outcomes, we continue to consider Integra the only dermal substitute able to create dermis with aesthetic and functional outcomes similar to normal skin and the only dermal substitute for regenerative medicine.

Both ventral and dorsal operative approaches have been used to treat unilateral cervical facet injuries. The gold standard ventral approach is anterior cervical discectomy and fusion. There is, however, no clear gold standard dorsal operation. In this study, the authors tested the stability of multiple posterior constructs, including unilateral lateral mass fixation supplemented by an interspinous cable. Six fresh human cervical spine specimens (C3-T1) were tested by applying pure moments to the C-3 vertebral body in increments of 0.5 Nm from 0 Nm to 2.0 Nm. Each specimen was tested in the following 8 conditions (in the order shown): 1) intact; 2) after destabilization via injury to the C5-6 facet; 3) with bilateral C5-6 lateral mass screws and rods; 4) after further destabilization by creating a right unilateral lateral mass fracture of C-5 (which rendered secure screw placement into the right C-5 lateral mass impossible); 5) with unilateral left C5-6 lateral mass screws and rod; 6) with unilateral C5-6 lateral mass screws and rod supplemented with an interspinous cable; 7) with a bilateral multilevel dorsal construct C4-6; and 8) after a C5-6 anterior cervical discectomy and fusion (ACDF) procedure with a polyetheretherketone graft and plate. The bilateral C5-6 lateral mass construct reduced the range of C5-6 motion to 33.6% of normal. The unilateral C5-6 lateral mass construct resulted in an increased range of motion to 110.1% of normal. The unilateral lateral mass construct supplemented by an interspinous cable reduced the C5-6 range of motion to 89.4% of normal. The bilateral C4-6 lateral mass construct reduced the C5-6 range of motion to 44.2% of normal. The C5-6 ACDF construct reduced the C5-6 range of motion to 62.6% of normal. The unilateral lateral mass construct supplemented by an interspinous cable does reduce range of motion compared with an intact specimen, but is significantly inferior to a C4-6 bilateral lateral mass construct. When using a dorsal approach, the unilateral construct with a cable should only be considered in selected instances.

Correcting gender dysphoria –the anatomical changes with male to female gender reassignment surgery

One Stage Urethroplasty in Severe Hypospadias Using Buccal Mucosa and Longitudinal Penile Island Flap

From March 1982 to December 1992, 30 cases of thumb reconstruction with a free neurovascular wrap-around flap from the big toe were performed at Korea University Hospital. Twenty-nine of a total of 30 cases were successful and obtained excellent functional and cosmetic results. Postoperative complications included 1 case of graft failure, 6 partial skin necroses, 1 malunion, and 15 cases of resorption of iliac bone graft including 1 case of fatigue fracture of grafted bone. Even for the first metacarpal neck amputations, thumb reconstruction with a free neurovascular wrap-around flap was possible; however, limitation of motion of the reconstructed thumb and resorption of the grafted bone occurred. Thumb reconstruction with a wrap-around free flap from the big toe gives excellent cosmetic and functional results and causes minimal morbidity on the donor site.

Management of osteoradionecrosis (ORN) remains a difficult and challenging problem. The traditional approach using debridement, antibiotics, and occasionally hyperbaric oxygen is usually successful in treating minimal ORN. However, when bone and soft-tissue necrosis is extensive, the conservative approach usually requires intensive care over a long period of time and often yields unsatisfactory functional and cosmetic results. Within the past 5 years, we have used radical resection of the mandible with immediate microvascular reconstruction in the treatment of extensive ORN of the mandible. This aggressive surgical approach was used in six patients with advanced ORN of the mandible, all of whom had failed initial conservative treatment, including hyperbaric oxygen therapy in three. A fibular free graft with microvascular anastomosis was used in all patients. All the patients healed primarily with minimal postoperative morbidity and excellent cosmetic results. Two patients subsequently required removal of some of their hardware. One patient had placement of osseointegrated implants with an excellent cosmetic and functional result. Microvascular reconstruction with its own blood supply seems to expedite bone healing and limit further osteoradionecrosis of the remaining mandible. Although prevention is the primary goal in radiation injury, our experience suggests that radical resection with free microvascular reconstruction offers significant advantages to selected patients with extensive ORN of the mandible.

Neonatal Management of Female Intersex by Clitorovaginoplasty

To report our experience with protractor myectomy in patients with benign essential blepharospasm who did not respond to serial botulinum toxin injection, and to describe intra- and postoperative techniques that limited skin contracture while also providing excellent functional and cosmetic results. The medical records of patients with isolated, benign, essential blepharospasm who underwent protractor myectomy from 2005 to 2008 by a single surgeon were reviewed retrospectively. The technique entailed operating on a single eyelid during each procedure, using a complete en bloc resection of all orbicularis tissue, leaving all eyelid skin intact at the time of surgery, and placing the lid under stretch with Frost suture and applying a pressure dressing for 5-7 days. Data from 28 eyelids in 7 patients were included. Average follow-up was 21.5 months (range, 4-76 months). Of the 28 eyelids, 20 (71.4%) showed postoperative resolution of spasm, with no further need for botulinum toxin injections. In the 8 eyelids requiring further injections, the average time to injection after surgery was 194 days (range, 78-323 days), and the average number of injections was 12 (range, 2-23 injections). All but one eyelid had excellent cosmetic results, without signs of contracture; one eyelid developed postoperative skin contracture following premature removal of the Frost suture and pressure dressing because of concerns over increased intraocular pressure. In our patient cohort, this modified technique resulted in excellent cosmetic and functional results and limited postoperative skin contracture.