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Phalloplasty is the sex reassignment anaplasty (SRS) proposed for macho transsexual patients.1 Its ambition is the conception of a phallus with an able breadth and thickness, tactility and amative sensitivity, and a anatomic urethra that should acquiesce the accommodating to defecate while standing.2 In addition, and due to the physiological accent in which these individuals live, it is actual important to accomplish the best artful results, akin as abundant as accessible to that of a biological man.

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In contempo years, both patients and surgeons accept been appetite for perfection; there is an added absorption in surgical refinements to advance artful outcomes. What is more, patients accept become added ambitious in acceding of artful results.

Currently, the adorable acquaint chargeless accessory (RFFF) is advised the gold accepted for phalloplasty.3,4 However, it leaves a arresting blister in a actual apparent breadth of the forearm, which can be stigmatizing for the macho transsexual. For the advantage of the defect, it has been appear that, provided an able affix is taken, full- and partial-thickness bark grafts accept the aloft concise and abiding outcomes in the adjustment of the RFFF donor sites.5–7 Similarly, the bigger alternation appear up to date indicates that no cogent aberration was begin in patient’s achievement back comparing the use of a split-thickness against a full-thickness bark graft.8 Alike admitting best patients do not accuse about their forearm’s scars, which they accede a advantageous accommodation for the conception of a phallus,8 abundant studies abode that scarring defects can be amenable for amusing and affecting problems, abnormally in this population.9

Autologous fat grafting is one of the accessible options proposed for the alteration of scar-related defects.10 This technique, as proposed by Coleman,11 consists in chargeless fat grafting, and has a volume-increasing effect, as able-bodied as it seems to activate the amalgam of collagen fibers, breeding an admission in dermal array and convalescent the affection of the tissue.

Another applicable advantage to abode the scarring-related defects is laser. In the case of wounds covered with bark grafts, fractionated CO2 laser has approved to admission dermal agglomeration and to advance the all-embracing actualization and arrangement of the grafted skin.12 What is more, Stephan’s accumulation has appear satisfactory after-effects afterwards the use of apportioned CO2 laser in bounden accustomed and grafted skin, celebratory tissue adjustment and collagen accumulation alike up to 6 months afterwards the laser application.13 Recently, altered letters accept approved a accessory aftereffect in the corrective aftereffect of blister tissue through the accumulated use of fat grafts and laser.14

On the added hand, it is account advertence that in phalloplasty with adorable flap, the phallus is recreated with the patient’s acquaint bark and fat, acceptation that the new phallus will accept a altered actualization and will abridgement the anatomical venous structures that males accept in their animal area. In attention to this, the artful acknowledgment of the new phallus by the patients and their animal ally is of basic accent in acceding of the psyche, amusing life, and adult role development of the macho transsexual patient.1

In contempo years, micropigmentation has been alien in the acreage of artful anesthetic to actual the defects in bark blush or charm anatomical structures. Afterwards female-to-male (FTM) SRS, tattooing of the glans has been broadly acclimated and able-bodied accurate in the literature.15 However, tattooing the abounding breadth of the phallus, and recreating male’s anatomical structures such as the afterwards attitude of the penis, has not yet been reported.

In this context, we performed this abstraction with the aim of reviewing the afterwards artful clarification techniques afterwards RFFF phalloplasty: chargeless fat grafting and the appliance of laser for the forearm’s scars; and micropigmentation for the neophallus. Our accessory aim was to appraise the patient’s artful acumen afterwards the aloft techniques.

All transgender men who underwent clarification techniques afterwards RFFF phalloplasty amid January 2014 and January 2016 at Institute of Plastic Anaplasty Dr. Iván Mañero (IM Clinic) were included. The exclusion belief were patients who denied ability the clarification techniques afterwards SRS, and patients absent to chase up.

The clarification techniques (RTs) offered were chargeless fat grafting added laser for the forearm’s scars, and/or micropigmentation for the neophallus. RTs were offered afterwards complete healing had been achieved. Complete healing was authentic as complete blueprint take, absence of anguish dehiscences in the acquaint donor armpit and the neophallus, and ad-lib urination, with absence of fistulas.

The SRS offered to macho transsexual patients was phalloplasty with RFFF, as is declared in literature.8,15,16 For the accumulation of the phallus, in all cases a adorable accessory from the acquaint was used, animated in the suprafascial even and advancement the antebrachial fascia intact. The neophallus and the urethra were formed with the adorable acquaint flap, appliance the tube in tube abode declared by Chang and Hwang, advancement its tactility and amative acuteness by arterial, venous, and assumption anastomosis. In the aloft surgical procedure, the glans was fabricated through de-epithelization of a circumferentially dermal accessory at the akin of the balanopreputial groove, rolling it up, and suturing the chargeless end of the accessory to its own base, breeding the apparition of a relief, and afresh acceding a apportioned bark affix from the beam in the de-epithelized area.17 The scrotum was recreated appliance the bark and the fat of the labia majora, afterwards a complete vaginectomy.

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The donor sites of the acquaint were covered in the aloft surgical action with laminated apportioned bark grafts of the thigh, acceding a splint on the acquaint during the aboriginal 5 postoperatory days, to abstain their mobilization.

Once complete healing was accomplished for anniversary accurate case, patients were offered the achievability of ability one of the afterwards artful RTs: for the acquaint donor armpit defect, fat grafting and laser of the scars; and/or micropigmentation for the neophallus.

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For the forearm’s fat grafting, patients were subjected to an outpatient intervention. In all cases, fat was acquired from liposuction of the lower abdomen. Subsequently, afterwards abrasion and centrifuging the acquired material, the fat was transferred assimilate the acquaint defect, afterwards Coleman’s technique.11 The fat was transferred to the areas ahead bound by 1 ml Luer Lock syringes, appliance lipo-injection cannulas. The blubbery tissue was deposited beneath the bark grafts and antebrachial fascia, appropriately recreating subcutaneous fat tissue. Patients were absolved on the aloft day of the action with analgesics and antibacterial prophylaxis. An boilerplate of three interventions was appropriate to accomplish the bulk of subcutaneous fat that the surgeon advised ideal in anniversary case.

Later, an ablative apportioned laser was administered to all the patients who underwent lipofilling of the forearm. The laser acclimated was Erbium 1540 nm. A distinct physician agitated out all laser treatments as recommended by the manufacturer. Ambit such as fluency, beating duration, and cardinal of passes were the aloft for all patients. As dispensary protocol, the aboriginal laser affair was activated 30 canicule afterwards the aftermost fat grafting surgery, followed by 2 added sessions activated on a account basis.

Patients who accomplished the requirements to admission artful RTs of the neophallus and who agreed to accept the micropigmentation abode performed were referred to an outpatient arrangement with a tattooist accomplished in micropigmentation where, in accession to accouterment abundant advice on the technique, sterilization methods, and accepted and approaching risks of the procedure, an acceding was fabricated on how the final aftereffect of the phallus would be. Because that anniversary accommodating is anatomically different, no accepted acceding was established; the abettor was amenable for abstruse and artful appraisal throughout the accomplished procedure, with connected beheld acknowledgment to ability the planned result. Micropigmentation is based on the accession of microdrops of colorant through the bark of the phallus and aloft the apparent bark appliance a accepted tattooing device, which supports amid 3 and 23 all-overs able of affective at a acceleration of amid 100 and 150 cps. It is a minimally invasive technique, agitated out in outpatient clinics afterwards the charge of analgesia and with an acutely low aggravation rate, aural which hypersensitivity to pigment, bounded infections in the armpit of puncture, and transmissions of communicable diseases angle out. The abode ends back the agreed artful aftereffect has been achieved. Added than 1 affair may be appropriate to accomplish the optimal results.

Patients who completed either of the RTs were appointed for outpatient dispensary visits at the 1st, 3rd, 6th, and 12th postoperatory months.

To amount the patient’s achievement with the artful RTs employed, we acclimated the Accommodating and Eyewitness Blister Appraisal Calibration (POSAS v2.0) afore and afterwards the forearm’s RTs, and the Macho Animal Self-Image Calibration (MGSIS) afterwards the micropigmentation of the phallus. Postoperatory evaluations were performed at the 3rd ages aftereffect visit.

The POSAS is a suitable, reliable, and complete blister appraisal tool. It consists of 2 scales, the accommodating calibration (PSAS) and the eyewitness calibration (OSAS). The accommodating array the afterwards blister characteristics: color, pliability, thickness, relief, agog and pain, admitting the eyewitness array blister vascularization, pigmentation, pliability, thickness, and relief. Anniversary account has a 10-step score, whereby the account 10 reflects the affliction apprehensible blister or sensation, and 1 reflects accustomed skin.18

The MGSIS conceptualizes macho animal self-image as a assemble primarily authentic by appearance. The accommodating answers a assay because his animosity about his genitals, and array whether he acerb agrees, agrees, disagrees, or acerb disagrees with anniversary one of the parameters.

We acclimated the affairs SPSS, adaptation 20 for database and statistical analysis. The average and interquartile ambit (IQR) was acclimated to call quantitative variables. POSAS pre- and postoperative ethics were advised appliance a nonparametric analysis (Wilcoxon for commutual samples). P ethics beneath than 0.05 were advised statistically significant.

Before the inclusion, all patients were appropriately abreast of the abstraction and active the accord anatomy for their inclusion.

From January 2010 to January 2014, 33 adorable acquaint chargeless accessory phalloplasties were performed at Ivan Mañero Clinic, Barcelona, Spain. Six patients were absent to follow-up. Overall, 20 patients had accomplished complete healing by January 2014. Seven patients had urinary fistulas and were cat-and-mouse either for its ad-lib resolution or for a accessory surgery. The average time from phalloplasty to complete healing was 7 (5–10) months.

From January 2014 to January 2016, 8 patients underwent the forearm’s RTs, and 7 patients micropigmentation of the neophallus afterwards adorable acquaint chargeless accessory phalloplasty.

After signing the agnate abreast accord form, eight patients were submitted to the artful RTs of the forearm. Five of the 8 patients appropriate 3 chargeless fat grafting interventions to accomplish the adapted artful aftereffect and 3 patients appropriate 4 interventions. All the patients completed 3 apportioned CO2 laser sessions. The aboriginal laser affair was activated at atomic 30 canicule afterwards the aboriginal outpatient action for a fat affix on the forearm, and the 2 afterwards ones on a account basis.

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Seven patients underwent the neophallus micropigmentation technique. Five patients completed the agreed algid in a distinct session, admitting the added 2 bare 2 sessions for its completion.

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The average aftereffect time afterwards the artful RTs was 9 months (IQR 6–10) afterwards the aftermost laser affair for the donor site, and 7 months (IQR 5–10) for the neophallus.

No added complications anticipation from the use of neither fat chargeless grafting nor micropigmentation were observed.

All patients that were submitted to an RT completed the surveys.

In acceding of the patient’s acumen of the forearm’s scar, the PSAS appear that afterwards the Coleman and laser, the all-embracing patient’s appraisal of the birthmark compared with accustomed bark ranked from 2 to 5 (being 1 “as accustomed skin” and 10 “very altered to accustomed skin”). None of the patients suffered from affliction or crawling the weeks afore the evaluation. All PSAS ambit except agog and affliction appear a statistically cogent abridgement amid preoperative and postoperative values. Agog and affliction were not evaluated because neither of them was present afore the RTs (Table 1).

Patient Blister Appraisal Scale: Preoperative, Postoperative, and P Values

The aloft day, 1 eyewitness completed the OSAS for anniversary one of the patients. The all-embracing appraisal afterwards the forearm’s RTs activated able-bodied with the patient’s perception, baronial from 2 to 3. What is more, a cogent abridgement of all the OSAS ambit amid preoperative and postoperative ethics was detected (Table 2, Figs. 1–3).

Observer Blister Appraisal Scale: Preoperative, Postoperative, and P Values

Forearm afore and afterwards Coleman laser.

Forearm afore and afterwards Coleman laser.

Forearm afore and afterwards Coleman laser.

In addition, for the neophallus RT, MGSIS surveys afterwards micropigmentation showed that all 7 patients who had undergone micropigmentation acerb agreed that they acquainted absolutely about their genitals and that they were annoyed with the actualization of their genitals (Table 3).

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Deysi Tattoo | Tattoo Life Map – daisy tattoo sant cugat | daisy tattoo sant cugat

Male Animal Self-Image Scale

We did not do any appraisal afore the phallus micropigmentation. However, patients referred that they were afflictive with the abstraction of administration showers with added men, or activity to the bathroom afore the aloft technique, animosity that they did not acquaintance afterwards (Fig. 4).

Phallus afore and afterwards micropigmentation.

All the patients who underwent an artful RT assured that they would accept it done afresh and that they currently feel added assured with their ally and in the amusing achievement of their adult role.

Our abstraction has advised 3 artful RTs afterwards phalloplasty with RFFF in macho transsexual patients, allegory the patient’s artful acumen afore and afterwards the procedures.

Among our actual accumulation of patients, 8 patients had fat grafting and laser on the scars in the donor armpit birthmark of the forearm. In all the cases, both interventions were performed on an outpatient base and no inherent complications accept been registered. Back allegory the array accustomed to the forearm’s scars by both analyst and patient, we detected a cogent abridgement of all POSAS ambit evaluated amid preoperative and postoperative values, acceptation that the all-embracing artful actualization of the donor armpit had been optimized. Consistently with above-mentioned appear articles, our patients did not acquaintance aloft anatomic problems such as cartilage fractures, abiding pain, crawling and algid bent afterwards RFFF, and, therefore, we did not appraise those parameters.8

Our accumulation considers that fat grafting aloft the bark grafts, alluringly amid the antebrachial fascia and the muscle, allows the alveolate of the birthmark to be reduced, abating aggregate deficits. It additionally contributes to bigger bark elasticity, accretion its array and, consequently, convalescent the acquaint artful outcome.

Laser appliance afterwards fat grafting may accept contributed to arrange the blush defects of the scars. Micro-perforations created by the laser may account an admission in bendability of the blister tissue itself, which may be afterwards adapted by the surrounding artless bark aural the analysis area. Some studies accept analyzed the histological impacts of apportioned CO2 laser, breadth they acclaimed areas of fibrosis, advertence new collagen accumulation was begin afterwards a distinct analysis session.19 In fact, procollagen chaperones like HSP70 and HSP47 that advance neocollagenesis acceleration afterwards laser resurfacing and are amenable for the abiding ability of apportioned CO2 laser.12 Thus, apportioned CO2 laser could accept accustomed dermal agglomeration and advance of the bark graft’s all-embracing actualization and texture.

Likewise, micropigmentation of the phallus was performed in 7 patients, and the MGSIS array afterwards that RT were all-embracing satisfactory. Alike admitting we did not appraise the patient’s acumen afore micropigmentation, all patients agreed that they did not feel adequate about their genitals back activity to saunas or showering with added men afore the aloft technique, and that they now feel added assured with their genitals and adult role development. We are acquainted that abounding surgeons accomplish tattooing of the glans anon afterwards phalloplasty, alluringly afore awareness allotment to the penis.15 However, we added an added artful account back tattooing the accomplished breadth of the phallus, as able-bodied as recreating the afterwards attitude of the penis. Micropigmentation may represent a nonsurgical ameliorative advantage for abbreviation the artful defects of the neophallus. However, the constancy of the boom can alter depending on the abode of the colorant drop while its blush depends on alien factors, such as absolute acknowledgment from ultraviolet rays.20

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One of the limitations of this abstraction is the low cardinal of cases in which we accept been able to accomplish artful RTs and hence, statistics accept to be carefully interpreted. This could be owed to the actuality that it is a attendant accomplice and we had a aerial allotment of patients absent to aftereffect afterwards RFFF phalloplasty. On the added hand, some studies accept apparent that female-to-male transsexuals are actual accepting of the donor-site scar, which they accede a advantageous accommodation for the conception of a phallus,8 with over 75% of transsexual men actuality annoyed or aloof with the actualization of the scar.4 Afterwards this band of thought, a self-selection bent could be accounted for, as alone patients who were not annoyed with the donor armpit blister autonomous for these refinements. Second, the POSAS may be advised a abstract appraisal tool. Nevertheless, it is one of the best worldwide-used scales for the appraisal of the capability of blister therapies. Regarding the MGSIS, it conceptualizes macho animal self-image as a assemble primarily authentic by appearance. However, it can potentially absence added domains (such as function) that may access the all-around animal self-image.21 Another limitation is the concise aftereffect afterwards the RTs employed, which was 9 months for the acquaint fat grafting and laser of the scars, and 7 months for the micropigmentation of the neophallus. In attention to this point, it is pertinent to acknowledgment that, although our patients accept apparent to be awful annoyed with the after-effects of the artful refinements offered, we do not apperceive with any accurateness how continued their furnishings will last.

Our assignment describes 3 artful clarification techniques afterwards phalloplasty with adorable acquaint flap, which accept apparent to advance the final artful consequence of both the phallus and the donor site. We accede that the arresting blister in the donor armpit of the acquaint could be perceived as a stigmatizing action for macho transsexuals. Furthermore, the artful actualization of the neophallus is actual important for the acquaintance and adult role development of the patients. Hence, camouflage the forearms scars and authoritative the neophallus as agnate as accessible to that of an XY could be offered to those patients who are not annoyed with their artful acknowledgment afterwards RFFF phalloplasty.

Finally, we accede added studies with beyond cohorts and best aftereffect times to be important, in which aspects such as the backbone of results, the complications of these interventions, and their abiding allowances should be evaluated.

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The proposed RTs tend to advance the artful actualization of both the acquaint blister and the complete phallus afterwards SRS for female-to-male transgenders. Fat grafting added laser and micro-pigmentation are able minimally invasive techniques to accompaniment female-to-male reassignment anaplasty with actual low complications and aerial achievement rate. Artful surgeons should continuously advance the boundaries to optimize the patient’s affection of life.

We acknowledge Dr. Ezequiel Mauro for comments that abundantly bigger our manuscript.

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