Male-to-female vaginoplasty: Preecha's surgical technique.

The inverted peno-scrotal flap is considered the standard technique for vaginoplasty in male-to-female transsexuals. Nowadays, great importance is also given by patients to the reconstruction of the clitoro-labial complex; this is also reconstructed with tissue coming from glans penis, penile skin envelop and scrotal skin. Since the first sex reassignment surgery for biological males performed in Thailand in 1975, Dr Preecha and his team developed the surgical technique for vaginoplasty; many refinements have been introduced during the past 40 years, with nearly 3000 patients operated on. The scope of this paper is to present the surgical technique currently in use for vaginoplasty and clitoro-labioplasty and the refinements introduced at the Chulalongkorn University and at the Preecha Aesthetic Institute, Bangkok, Thailand. These refinements consist of cavity dissection with blunt technique, the use of skin graft in addition to the penile flap, shaping of the clitoris complex from penis glans and clitoral hood, and the use of the urethral mucosa to line the anterior fourchette of the neo-vagina. With the refinements introduced, it has been possible to achieve a result that is very close to the biological female genitalia.

The development of sex reassignment surgery in Thailand: a social perspective.

This paper reviews the development of gender reassignment in Thailand during the period of 1975-2012, in terms of social attitude, epidemiology, surgical patients' profile, law and regulation, religion, and patients' path from psychiatric assessment to surgery. Thailand healthcare for transsexual patients is described. Figures related to the number of sex reassignment surgeries performed in Thailand over the past 30 years are reported. Transsexual individuals are only apparently integrated within the Thail society: the law system of Thailand in fact, does not guarantee to transsexuals the same rights as in other Western countries; the governmental healthcare does not offer free treatments for transsexual patients. In favor of the transsexual healthcare, instead, the Medical Council of Thailand recently published a policy entitled "Criteria for the treatment of sex change, Census 2009." The goal of this policy was to improve the care of transsexual patients in Thailand, by implementing the Standards of Care of the World Professional Association of Transgender Health. Currently, in Thailand, there are 6 major private groups performing sex reassignment surgery, and mostly performing surgery to patients coming from abroad. Particularly, the largest of these (Preecha's group) has performed nearly 3000 vaginoplasties for male-to-female transsexuals in the last 30 years.

Comparative study between chitin/polyacrylic acid (PAA) dressing, lipido-colloid absorbent dressing and alginate wound dressing: a pilot study in the treatment of partial-thickness wound.

BACKGROUND: Polyacrylic acid grafted chitin (Chitin-PAA) contains a hydrogel characteristic that makes it more suitable for wound dressing application. In animal models, Chitin-PAA dressing exhibited properties as a promising dressing. Epithelization promotion, rapid reduction of wound size, reduction of inflammatory cell response, and less toxicity had been noted. OBJECTIVE: Carryout a pilot clinical comparative study of Chitin-PAA dressing, lipido-colloid absorbent dressing, and alginate wound dressing in the treatment of partial-thickness wound. MATERIAL AND METHOD: Between June 2006 and March 2007, 36 partial-thickness wounds were randomized into three groups and three different types of dressing were used. Each wound was treated until it was completely healed, and a visual analogue scale was used for the pain evaluation. RESULT: The present study shows the visual analogue pain score in the Chitin-PAA group seems to be a bit higher than the Urgocell group but not statistically different. The completely healed day is not significantly different. Three patients in the lipido-colloid absorbent dressing groups had wound infection but eventually healed after treatment. CONCLUSION: There was no statistical difference in terms of visual analogue pain score and healing time between the lipido-colloid absorbent dressing, alginate dressing, and chitin-PAA dressing.

The anatomy of the thoracodorsal artery in perforator flap for resurfacing shallow defect.

OBJECTIVE: To systematically determine the location and number of cutaneous perforators greater than 0. 5 mm in diameter of the lateral branch of the thoracodorsal artery perforator flap for resurfacing shallow defect. MATERIAL AND METHOD: Sixty dissections of the thoracodorsal arterial system were carried out in 30 preserved cadavers. The location and number of cutaneous perforators greater than 0.5 mm in diameter of the lateral branch of the thoracodorsal artery perforator flap were studied and measured. RESULTS: Seventy-six perforators were found in 60 flaps (1.3 perforators per flap). The first perforator was exited in all dissections. It emerged from the latissimus dorsi muscle 9.8 cm below the dome of the axilla. In 21.67% of the cases, the second perforator of the thoracodorsal artery arose 3.4 cm distal to the origin of the first perforator The third perforator was found in 5% of dissections, and originated 3.0 cm away from the origin of the second perforator In addition, most perforators penetrated the muscle within 7.0-14. 0 cm below the dome of the axilla. CONCLUSION: The center of the flap designed should be placed between 7 to 14 cm from the dome of the axilla.

Neurovascular anatomy of the deep inferior epigastric perforator flap for breast reconstruction.

OBJECTIVE: To find out the most suitable perforator and cutaneous nerve for strategic design of the deep inferior epigastric perforator (DIEP) flap. MATERIAL AND METHOD: The characteristics of the pedicles, perforators, intercostal nerves and the relationship between nerves and vessels in DIEP flaps were studied in 31 formalin-preserved cadavers. RESULTS: Four hundred and five perforator vessels were divided into three vertical rows. These perforators were mostly contained in the medial row (45.4%), the average size of the perforators in the lateral row was the largest (1.0+/- 0.3 mm). The largest perforators (1.4+/- 0.3 mm) were mostly located within 1 cm horizontally from the umbilicus. Lateral row perforators, usually rectilinear course (82.7%), traveled with nerves from the beginning. Whereas, the perforators in the medial row usually coursed obliquely (86.4%) and were not related to nerves initially, they joined before piercing the rectus sheath. CONCLUSION: The present findings indicate that it would be more beneficial to use the lateral row perforators.

Bilateral scrotal flaps: a skin restoration for penile paraffinoma.

Foreign body injection into the penile shaft, in the mistaken belief that it could increase the size, is not uncommon among Thai males. Paraffin, oil, and other materials had been injected into the penile skin and predictably followed by a lot of complications. Foreign body granuloma, disfigurement, chronic and unhealed ulcer, painful erection, and the inability to achieve sexual activities are those following complications. In the severe cases, even though the complete resection of the skin and all of the infiltrated tissue was meticulously performed, some foreign bodies had to be left since they had incorporated into either the corpus cavernosum or corpus spongiosum. Durable resurfacing skin can't be perfectly achieved by skin grafting in these situations. Between 1996 and 2002, 31 patients with penile paraffinoma have been treated using bilateral scrotal flaps. Both functional and cosmetic goals without any major complications were achieved in all of the patients.

The role of SMAS flap in preventing Frey's syndrome following standard superficial parotidectomy.

Between 1992 and 2002, 46 patients who underwent standard superficial parotidectomy with a superficial muscoloaponeurotic system (SMAS) preservation technique were included in a retrospective study. Twenty-six patients were evaluated by questionnaire for subjective symptoms of gustatory sweating and flushing as well as satisfaction with the aesthetic appearance of their cheek. Six of twenty-six patients (23.1%) complained of symptoms of Frey's syndrome. Seven of twenty-six patients (26.9%) demonstrated a positive Minor's starch iodine test. By this technique the incidence of Frey's syndrome is substantially reduced from 48% by subjective review and 72% by objective measurement reported in the previous study by the same group of surgeons without using the SMAS preservation technique. This study supports the role of the SMAS flap in preventing Frey's syndrome following standard superficial parotidectomy.

Sex reassignment surgery in Thailand.

Many years ago Thai society considered transsexualism (Gender identity disorder or Gender dysphoria) which is commonly known as Kathoey (a word originally used to denote hermaphrodites), Sao Prapet Song or Tut (as in 'Tootsie') were low class citizens, dirty dressing and had to hide in a dark corner selling their services as prostitutes. This made us unwilling to do sex reassignment surgery for this group of people because the idea of eradicating normal sexual organs for the purpose that was not accepted by the society. Consequently the authors have experience in cases where these people wandered seeking doctors who had no competency nor enough experience to do the surgery. The authors could not inhibit the desire of these people who usually suffer from gender identity disorder from strongly wishing to change their genital sex to the sex they want. The outcome of the surgery was not satisfactory for the patients. There were complications and sequelae which caused the authors to correct them later which might be more difficult than doing the original surgery. In addition there were more studies about the etiology and affect of the disorder on these people that changed the social point of view. The women who wanted to be a him and men who would like to be a her should be considered as patients who need to be cured to set the harmony about their genetic sex and the desire to be the opposite sex and also to be regarded by others as a member of that other sex. The treatments of transsexualism usually begin with conventional psychiatric and endocrinological treatment to adjust the mind to the body. For those who failed conservative treatment in adjusting the mind to the body then sex reassignment surgery will be the only way to transform their body to their mind and give the best result in properly selected patients. Preecha Tiewtranon, the pioneer in sex reassignment surgery in Thailand, did his transsexualism case in 1975 together with Dr. Prakob Thongpeaw. Sex reassignment surgery has been taught in Chulalongkorn University Hospital since 1983. (At present, it is the only medical school in Thailand that has sex reassignment surgery systematically taught and with good results). There have been many versions of development of the surgical techniques to gain better and better results.