Is vaginal mucosal graft the excellent substitute material for urethral reconstruction in female-to-male transsexuals?

PURPOSE: Construction of a neourethra is always considered to be a difficult part in phalloplasty, especially for the female-to-male (FTM) transsexual patients. We report our experience with prefabricated pars pendulans urethrae using vaginal mucosal graft for phalloplasty in FTM transsexuals. MATERIALS AND METHODS: We retrospectively reviewed notes on the 22 FTM patients treated with pedicled-flap phalloplasty with prefabricated pars pendulans urethrae using vaginal mucosal graft between January 2008 and December 2012. Surgical outcome, urological function, and complications were recorded. Histological difference between normal mucosa and skin, and pathological changes of vaginal mucosal graft were also observed. RESULTS: All the reconstructive penis survived, and patients could void in a standing position finally at a median follow-up of 25.4 ± 6.0 months. Urethral fistula and urethral stricture rates were 31.8 % (7/22 patients) and 4.5 % (1/22 patients), respectively. The occurrence of the urethral stricture was remarkably low compared with previous reports. Our histological results also showed a pronounced similarity between vaginal and buccal mucosa. Morphologically, they resembled urethral epithelium more closely than the forearm skin. Following the free transfer, the vaginal mucosal graft also showed a good revascularization and the inflammatory reaction and the extent of fibrosis of the mucosa decreased to the normal level after a 6-month prefabrication. CONCLUSION: With prefabrication of vaginal mucosal graft, we reconstruct a competent phallic neourethra in these FTM transsexuals. According to its histological similarities and source character, the vaginal mucosa is the excellent substitute material for promising urethral reconstruction in FTM transsexuals.

Architectural properties of the neuromuscular compartments in selected forearm skeletal muscles.

The purposes f this study were to (i) explore the possibility of splitting the selected forearm muscles into separate compartments in human subjects; (ii) quantify the architectural properties of each neuromuscular compartment; and (iii) discuss the implication of these properties in split tendon transfer procedures. Twenty upper limbs from 10 fresh human cadavers were used in this study. Ten limbs of five cadavers were used for intramuscular nerve study by modified Sihler's staining technique, which confirmed the neuromuscular compartments. The other 10 limbs were included for architectural analysis of neuromuscular compartments. The architectural features of the compartments including muscle weight, muscle length, fiber length, pennation angle, and sarcomere length were determined. Physiological cross-sectional area and fiber length/muscle length ratio were calculated. Five of the selected forearm muscles were ideal candidates for splitting, including flexor carpi ulnaris, flexor carpi radials, extensor carpi radialis brevis, extensor carpi ulnaris and pronator teres. The humeral head of pronator teres contained the longest fiber length (6.23 ± 0.31 cm), and the radial compartment of extensor carpi ulnaris contained the shortest (2.90 ± 0.28 cm). The ulnar compartment of flexor carpi ulnaris had the largest physiological cross-sectional area (5.17 ± 0.59 cm(2)), and the ulnar head of pronator teres had the smallest (0.67 ± 0.06 cm(2)). Fiber length/muscle length ratios of the neuromuscular compartments were relatively low (average 0.27 ± 0.09, range 0.18-0.39) except for the ulnar head of pronator teres, which had the highest one (0.72 ± 0.05). Using modified Sihler's technique, this research demonstrated that each compartment of these selected forearm muscles has its own neurovascular supply after being split along its central tendon. Data of the architectural properties of each neuromuscular compartment provide insight into the 'design' of their functional capability. In addition to improving our understanding of muscle anatomy and function, elucidation of forearm neuromuscular compartments architecture may ultimately provide information useful for selection of muscle subdivisions used in tendon transfer.

Laparoscope-assisted creation of a neovagina using pedicled ileum segment transfer.

BACKGROUND: To present our experience of vaginal reconstruction with the use of a pedicled ileum segment and laparoscope assistance, and to analyze its complications and long-term anatomic and functional results. METHODS: The abdominal and perineal approaches were performed simultaneously with the patient in a special position. Under the guidance of laparoscopy, the target ileal segment was harvested and transposed down to the perineum through an artificial tunnel between the bladder and the rectum. A silicon vaginal tutor was introduced into the vaginal cavity and maintained all day long for 2-3 months. The complications and the anatomical and functional results were summarized and analyzed. RESULTS: From February 2002 to June 2010, 82 patients underwent laparoscope-assisted total vaginal reconstruction with a pedicled ileum segment at our department. Complications developed in 16 of 82 patients, including rectum and/or bladder injury during operation, acute renal failure, delayed healing of the ileocutaneous anastomosis, introital stenosis, and partial or complete intestinal obstruction. The abdominal cutaneous scar was acceptable after the surgery. The vulva was not altered, which was especially significant for patients with congenital vaginal atresia. The neovagina was patent, soft, moist, and flexible. The mean width and depth of the neovagina at the latest postoperative visit measured 3.2 and 15 cm, respectively. CONCLUSIONS: The favorable long-term anatomical and functional results demonstrate that our technique is ideal for patients with congenital vaginal atresia or patients who need secondary vaginal reconstruction. For the primary male-to-female transsexuals or hermaphrodites, it can be an alternative method for vaginal construction.

Profiling of innervations of mimetic muscles in fresh human cadavers using a modified Sihler's technique.

The nerve map of the human face, although important in guiding facial surgery, has not been well defined. In this study we applied a modified Sihler's technique to profile intramuscular innervation of human mimetic muscles. Six fresh cadaveric heads were used. The intramuscular distribution of the facial nerve in human mimetic muscles was visualized using a modified Sihler's technique. Modified Sihler's staining revealed a three-dimensional picture of the clearly purple-black intramuscular facial and sensory nerves. The nerve branching patterns of both facial halves were asymmetrical. None of the fine nerve branches crossed over the midline. The facial nerve branches divided into secondary rami and formed a mesh-like plexus before entering the target muscles at a right angle. The modified Sihler's technique can profile intramuscular innervation of human mimetic muscles. Our nerve map of the face offers valuable guidance for facial reanimation surgery, facial cosmetic surgery, and parotid surgery.

Intramuscular innervations of muscle flaps that are commonly used in clinical settings.

PURPOSE: Abductor hallucis, latissimus dorsi, gracilis, rectus abdominis, sartorius and pectoralis minor are muscle flaps that are commonly used in clinic, but their intramuscular innervation has seldom been systematically investigated. METHODS: Five Chinese fresh human cadavers were included in the study and abductor hallucis, latissimus dorsi, gracilis, rectus abdominis, sartorius and pectoralis muscles were dissected. After gross anatomy measurement, the specimens were then stained by Sihler's staining technique. Intramuscular innervation was observed and the number as well as distribution was recorded. RESULTS: Intramuscular nerves were clearly visualized by Sihler's staining technique. Based on the shape and muscle-tendon morphology, Lim et al. in Muscle Nerve 29:523-530, 2004 grouped the muscles into trapezoidal-shaped (type I), spindle-shaped (type II), and combination-shaped (type III). According to Lim's study the abductor hallucis was a type IIb muscle and was divided into two compartments by the distal tendon. Latissimus dorsi was a type I muscle, divided into 3-4 compartments by intramuscular nerve branches. Gracilis was a type IIa muscle and the distal part was divided into two compartments by intramuscular nerve branches. Rectus abdominis was a type III muscle and the four bellies comprised four compartments, each of which could be designated as a subunit. Sartorius was a type II muscle and it could be divided into 2-3 compartments along the long axis. Pectoralis minor was a type I muscle that was divided into two compartments by extramuscular terminal nerves. CONCLUSIONS: The six muscles are divided into several compartments by the tendon or nerve branches, and all of them make good donor tissue for muscle compartment transfer in reconstructive surgery.

Neurovascular details about forearm muscles: applications in their clinical use in functional muscular transfer.

PURPOSE: The concept of muscle subunits has been introduced for limb reconstruction and functional conservation of donor site, yet it requires thorough understanding of neurovascular anatomy of muscles. The present study provides neurovascular details of forearm skeletal muscles. METHODS: Twenty-eight forearms were dissected totally, ten for observing extramuscular nerve distribution, ten for observing intramuscular nerve distribution by modified Sihler's technique, and the other eight for observing intramuscular artery distribution by aqueous barium sulfate infusion. The forearm muscles were classified into three different types according to Lym's classification. Numbers of extramuscular and intramuscular nerves were counted and compared between the types. Intramuscular vascular distribution was also classified into three different types according to Mathes' method. Intramuscular vascular distribution was compared with nerve distribution as well. RESULTS: There were also some variations in the composition of muscular branches. Numbers of intramuscular nerve branches were significantly higher in muscle types IIa and III. Morphology and intramuscular neurovascular distribution of type II muscles are easy to split into two independent parts for functional muscular flap transfer according to morphology and intramuscular neurovascular distribution. CONCLUSIONS: The present study elucidated that flexor carpi ulnaris and radialis, extensor carpi ulnaris, and carpi radialis brevis were suitable for functional muscular transfer from several different insights, but the roles of pronator teres and supinator remained to be controversial. This study might be very helpful to plastic surgeons and anatomists.

[Clinical application of Reading man flap].

OBJECTIVE: To investigate the effect of Reading man flap for the closure of round or elliptical-shaped defect. METHODS: Based on the asymmetric Z flaps, F1 (triangular flap) and F2 (rectangular flap) flaps were designed to cover the round or elliptical-shaped defects. The flaps size ranged from 0.8 cm x 0.8 cm to 9.0 cm x 8.0 cm. RESULTS: From 2008 to 2011, 32 cases were treated without infection or dog-ear deformity. Less than 5% of local necrosis happened in one flap, which healed spontaneously after dressing. Delayed healing happened in 5 cases. The scar after operation was inconspicuous. CONCLUSIONS: Reading man flap can be designed flexibly. It is a good option for the closure of round or elliptical-shaped defects.

Two methods can simultaneously display both intramuscular nerves and blood vessels.

BACKGROUND: The arrangement and relationship of intramuscular nerves and blood vessels are critical to clinical physicians, but the majority of previous studies could not reflect them precisely. METHODS: In method 1, after rabbits were perfused with barium sulfate liquid silica gel, the specimen muscle was isolated and subjected to Sihler staining. The specimen muscles then underwent optical photography and molybdenum target radiography. The obtained photograph and the radiograph were then overlapped together to draw a map of intramuscular nerves and blood vessels. In method 2, after rabbits and child cadavers were perfused with semitransparent red liquid silica gel, the specimen muscle was isolated and subjected to Sihler staining. Finally, the specimen muscles were placed on an x-ray film viewer for photography. RESULTS: Both methods had ideal outcomes. Through digital subtraction angiography, a distribution map of intramuscular nerves and blood vessels could be obtained in method 1, whereas in the photographs taken through method 2, the intramuscular nerves were counterstained with dark blue and the intramuscular blood vessels were stained red, which was more precise and direct. In method 2, specimens could be made into stereoscopic models. CONCLUSIONS: These two methods that can simultaneously display intramuscular nerves and blood vessels have been significantly improved and lead to a good result. They also have their own advantages. When a muscle studied is small or flat, method 2 is recommended because of its conciseness and convenience. If the muscle is large, method 1 is applicable.

Facial reanimation by one-stage microneurovascular free abductor hallucis muscle transplantation: personal experience and long-term outcomes.

BACKGROUND: In 1990, Jiang Hua introduced a new method using one-stage reconstruction with free abductor hallucis muscle transfer for dynamic reanimation of established unilateral facial paralysis. The authors present their experience with this procedure and analyze the postoperative complications and long-term functional and aesthetic outcomes. METHODS: From March of 1990 to March of 2010, 45 patients underwent the free abductor hallucis muscle transfer procedure in the authors' department. Forty-one were followed up for 54.6 months (range, 28 months to 17 years). The Toronto Facial Grading System and Facial Nerve Function Index were used to evaluate facial nerve function at 2 years after surgery and last follow-up. Complications and function of the donor foot were analyzed. RESULTS: No postoperative mortality was found. Complications occurred in four of 41 patients, including muscle loss, infection, hematoma, and hypertrophic scar. The others obtained satisfactory symmetric faces in the static state and in voluntary contraction of the transferred muscles. Mean values for the Toronto Facial Grading System (50.6±7.8) and the Facial Nerve Function Index (65.7±11.4 percent) were significantly higher at 2 years postoperatively in comparison with preoperative status (21.2±5.3 and 19.5±3.6 percent, respectively) (p<0.05). Long-term outcomes (Toronto Facial Grading System, 54.8±6.9; Facial Nerve Function Index, 79.4±9.6 percent) were awarded higher values than early outcomes shown at 2 years postoperatively (p<0.05). CONCLUSIONS: Free abductor hallucis muscle transfer is safe and effective in dynamic reanimation of longstanding unilateral facial paralysis. Favorable long-term results demonstrate that the authors' technique is an alternative method for facial reanimation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

[MAFbx and MuRF1 mRNA expression and its relationship with muscular contractility following free muscle transfer].

OBJECTIVE: To study muscle atrophy F-box (MAFbx) and muscle ring finger 1 (MuRF1) mRNA expression and its relationship with muscular contraction following free muscle transfer. METHODS: The gracilis muscle was orthotopic transferred in adult rat to establish the animal model. The muscle at the unoperated side was used as control. The expression of MAFbx and MuRF1 mRNA, the muscle contraction and muscle function were measured by real-time PCR and multiple function physiological device. The relationship among the expression of MAFbx and MuRF1 mRNA, the muscle contraction and muscle function was analyzed. RESULTS: After muscle free transfer, muscle wet weight reservation, the maximum contraction and tetanus strength reduce first and increased later, but still lower than those at control side. The expression of MAFbx and MuRF1 mRNA reached peak level 3 - 4 weeks after muscle transfer which was 7.1 and 4.1 times as that at control side. It decreased later, but still higher than that at control side, showing a significant difference between them (P< 0. 05). CONCLUSIONS: Persistent over-expression of MAFbx and MuRF1 mRNA after muscle transfer has a close relationship with muscle atrophy and muscle dysfunction. MAFbx and MuRF1 can be used as markers for early muscle atrophy, and also as potential target for drug treatment of muscle atrophy.

[Anatomic study of intramuscular nerve and blood vessel in forearm muscles: an anatomical study].

OBJECTIVE: To study the distribution of intramuscular nerve and blood vessels in forearm muscles and to discuss the possibility of dividing the forearm muscles into independent functional units. METHODS: (1) The muscles were dissected in 10 forearms from 5 fresh adult human cadavers and stained with the Sihler's nerve staining; (2) The blood vessels were studied in eight forearm muscles from 4 fresh adult human cadavers with irrigation of a mixture of 30% barium sulfate and gelatin from brachial artery and then X-photographed. All pictures were compared to study the intramuscular distribution of nerve and blood vessels. RESULTS: The intramuscular nerve branches were stained purple-black and visualized clearly. The muscles were classified into three types according to the distribution characters of intramuscular nerve and blood vessels. And the types of muscles could be further subdivided into a and b subtypes. CONCLUSION: According to the neurovascular distribution, the forearm muscles in type II a and type III a can be divided into independent function units for muscle functional transplantation.

[Anatomy of buccal and marginal mandibular branches of facial nerve and its clinical significance].

OBJECTIVE: To study the course and distribution of buccal and marginal mandibular branches of facial nerve, and its relevance to the treatment of facial paralysis and the protection of facial nerve during surgery. METHODS: 12 cadaver heads were dissected (24 specimens). The course of the buccal and marginal mandibular branch and the interconnections between them were observed. The relationship of buccal branch to parotid duct, marginal mandibular branch to the inferior border of mandible were studied. With modified Sihler's staining technique, the distribution of facial nerve branches in innervated mimetic muscles was displayed. These anatomic relationships mentioned above were further confirmed during the operation of 40 patients with facial paralysis. RESULTS: Parotid duct had a constant surface landmark. Buccal branch mainly consisted of 2-3 ramifications in 87.5% of the specimens, while marginal mandibular branch was double or single in 95.9% of the specimens. The buccal branch coursed within the distance between 10.7 mm above and 9.3 mm below the parotid duct, and innervated mimetic muscles of midface. The marginal mandibular branch coursed within the distance between 13.4 mm above and 4.8 mm below the lower border of mandible, crossed superiorly the facial artery and innervated mimetic muscles of lower lip. CONCLUSIONS: There is a close relationship of buccal branch to parotid duct and marginal mandibular branch to facial artery and lower border of mandible. With modified Sihler's staining technique, the original 3-dimensional picture of the intramuscular nerve distribution in human mimetic muscles.

[The neuromuscular compartments of the flexor carpi ulnaris and the flexor carpi radialis].

OBJECTIVE: Report on the intramuscular innervation and vascular supply of the flexor carpi ulnaris (FCU) and the flexor carpi radialis (FCR), the musculo tendon architecture, i.e., the physiological cross-sectional area and fiber length; and explore the possibility of splitting FCU and FCR into 2 parts with individual independent function. METHODS: Anatomic study, angiogram and Sibler's staining technique were carried on human and monkey cadavers. The electric stimulation study was used to reveal independent contraction of each part on monkey FCU and FCR. RESULTS: It was found that the innervation and blood supply of FCU and FCR come primarily from the proximal neurovascular pedicles. The primary nerve and vascular branch supplying the muscles were divided into 2 subbranches and inserted the proximal quarter of the muscle belly. Then each of the nerve and blood subbranches mn parallel to the central tendon on each side supplying the radial and ulnar compartments of FCU and FCR toward the distal musculotendinous junction. Independence of function of each compartment was confirmed in electrical stimulation studies in primate FCU and FCR. The results of each compartment of the human FCU and FCR architectures were measured and compared with the extensor pollicis longus and the extensor digitorum communis to the index, middle, ring, and small. CONCLUSIONS: Both FCU and FCR can be split from the distal to the proximal along its tendon into 2 independently functioning neuromuscular compartments. Both radial compartment and ulnar compartment have its own nerve and adequate blood supply. And the study provides useful information for enabling the local transfer of the two muscles as a whole or two separate compartments, both for resurfacing skin soft-tissue defects and for functional tendon transfer.

[Laparoscopic small intestinal flap colpopoiesis].

OBJECTIVE: To investigate the possibility of Laparoscopic reconstruction of vagina using pedicled ileal autograft and provide a new procedure of colpopoiesis. METHODS: The abdominal and perineal approaches were performed simultaneously under a sufficiently deep general anaesthesia. Laparoscopically, a 15-18 cm segment of the ileum on its vascular pedicle, ileal branches of the superior mesenteric artery and its concomitant veins, was selected and isolated for transplantation using ultrasonically-powered instruments. The distal of the transferred ileal segment was 15cm apart from the ileocecal junction. The ileum continuity was restored immediately by end-to-end anastomosis and the distal oral of the transplant was closed using a curved intraluminal stapler. Meanwhile, a neovaginal tract was completed to dissect from the perineum into the peritoneum and the tract widened laterally. Then the ileum transplant was reversed to reach the perineum through the peritoneal incision at the top of the neovaginal tract without subjecting the mesenteric neurovascular pedicle to undue tension and subsequent necrosis. The oral edge of the ileum transplant was sutured to the perineal skin. RESULTS: Followed up for over 1-53 months postoperatively, 36 patients who received laparoscopic vaginoplasty by transferring ileal segment flaps got satisfactory neovaginal function similar to a normal vagina with mucus and moistness. CONCLUSIONS: The advantages of using a laparoscopic ileum colpopoiesis are that (1) satisfactory neovaginal function similar to a normal vagina with mucus and moistness, (2) no disturbance of bowel function, (minimal scarring in abdominal wall and less secondary deformity in perineum and (3) no need for frequent dilation or stent wearing to the reconstructed vagina. And so laparoscopic vaginoplasty was a preferable alternative of vaginoplasty.