Trans men can achieve adequate muscular development through low-dose testosterone therapy: A long-term study on body composition changes.

BACKGROUND: Transgender individuals undergo the gender-affirming hormone therapy (GAHT) to achieve physical changes consistent with their gender identity. Few studies are available on the long-term safety and efficacy of GAHT. OBJECTIVES: To investigate the long-term physical effects and the safety of the testosterone therapy for trans men and to assess the impact of differential hormone dose. MATERIALS AND METHODS: Trans men who initiated GAHT between May 2000 and December 2021 were included in this retrospective analysis. Physical findings (body mass index, body fat percentage (BFP), lean body mass (LBM), and grip strength), blood testing results (hemoglobin, hematocrit, uric acid, creatinine, total cholesterol, triglycerides, and total testosterone), and menstrual cessation were recorded. We assessed the effects of testosterone on body composition changes and laboratory parameters, comparing a low-dose group (≤ 62.5 mg/wk) to a high-dose group (> 62.5 mg/wk). RESULTS: Of 291 participants, 188 patients (64.6%) were in the low-dose group and 103 (35.4%) in the high-dose group. Cumulative menstrual cessation rates up to 12 months were not significantly different between groups. Both groups showed a decrease in BFP and an increase in LBM during the first year of therapy, followed by a slight increase in both over the long term. The high-dose group exhibited greater LBM gains during the first year. Higher hormone doses and lower initial LBM values were associated with LBM increases at 3 and 6 months (3 mo, P = 0.006, P < 0.001; 6 mo, P = 0.015, P < 0.001). There were no long-term, dose-dependent side effects such as polycythemia or dyslipidemia. CONCLUSION: Long-term GAHT for trans men is safe and effective. Low-dose testosterone administration is sufficient to increase LBM in trans men. Higher testosterone doses can lead to an earlier increase in muscle mass.

Intraoperative local instillation anesthesia using injection technique from J-VACTM drain for postoperative pain relief in male-type chest wall contouring surgery.

For postoperative acute pain during mastectomy, a few studies have reported the usefulness of an intraoperative local anesthesia instillation technique in which analgesics are injected through a drain placed under the skin, intraoperatively. This study presented a novel administration method, and the efficacy of local instillation anesthesia in male-type chest wall contouring surgery was assessed. Fifty-four patients underwent chest wall contouring surgery under general anesthesia. The 27 patients in each of the study and control groups, with our instillation technique and without the technique were compared, in terms of the maximum numerical rating scale (NRS) score within 24 h after surgery, the postoperative analgesic use frequency, and dosage until 6 d. The analgesic used was a mixture of 5 ml 1% lidocaine hydrochloride, epinephrine (0.05 mg), 10 ml 0.75% bupivacaine, and 10 ml saline. Thereon, 25 ml analgesia was administered from the left and right drain (15-Fr J-VACTM) and infiltrated for 15 min. Both NRS scores of postanesthesia care unit (PACU) discharge and the maximum NRS score within 24 h after PACU discharge were significantly lower in the study group than in the control group (p < 0.001, p = 0.048). The frequency of analgesics administered within 24 h after surgery was significantly lower in the study group than in the control group (p = 0.025). Our anesthesia instillation method for chest wall contouring surgery was effective in relieving acute pain occurring within 24 h after surgery and can be a useful analgesic administration method.

Genital Feminizing Surgery without Vaginoplasty as a Safe, Aesthetic, and Cost-Effective Option for Gender-Affirming Surgery for Transwomen.

Gender affirming surgery (GAS) has important impacts for people with gender incongruence (GI), both physically and socially. As the societal acceptance of gender diversity spreads, the number of individuals with GI who wish to be identified as the gender of their choice is increasing. Indeed, many elderly people who have lived a long time with GI now wish to undergo GAS, but face greater surgical risks due to greater burdens of underlying medical conditions. Generally, vaginoplasty is performed for transwomen; however, this surgery is time-consuming and involves heavy bleeding, and thus, should be avoided in elderly people. A less invasive technique is needed. In this article, we describe a new, less invasive genital feminizing surgical technique for transwomen with reports from two clinical cases. We present this novel technique as a safe, aesthetic, and cost-effective option for gender-affirming surgery for transwomen.

The Novel Eryngii Method of Nipple Reduction for Female-to-Male Transsexuals.

Mastectomy is usually the first and most important surgical procedure in female-to-male (FTM) individuals with gender identity disorder. Nipple reduction is also important in the process of reconstructing the chest wall for a more male appearance. If the nipples remain large after a mastectomy, the results may be disappointing to many FTM transsexuals. Nipple reduction enables these individuals to go to the beach or Japanese public baths, where they may go topless in public. We therefore consider that nipple reduction is indicated for all FTM transsexuals who desire it. There are a variety of methods for the reduction of enlarged nipples for women or non-FTM patients, but only a few reports have described the process used to create masculine-appearing nipples for FTM transsexuals. We developed a novel technique called the Eryngii method for creating male-like nipples using a 4-mm diameter dermal punch knife. The name of the method refers to the Eryngii king trumpet mushroom, which the nipple resembles after the surgical process. The main strength of this method is that it permits the creation of ideal nipples without difficulty. Here we introduce the technique and discuss our history of surgical methods for nipple reduction, including improvements and elaborations.

Risk Factors for Postoperative Hematoma after Chest Wall Contouring for Female-to-Male Transsexuals: A Clinical Study.

Gender dysphoria is a condition in which a discrepancy between biological sex and gender identity causes distress. Many female-to-male transsexuals (FTMTS) are uncomfortable with female breasts. Chest wall contouring surgery is effective for obtaining a male-type chest, reducing mental stress, and increasing sexual satisfaction in such cases. At the Okayama University Hospital Gender Center, we have obtained positive results using an algorithm to determine the most appropriate surgical method for chest wall contouring in FTMTS patients. However, serious complications requiring reoperation, such as hematoma, may still occur. Postoperative hematomas were found in 15 (4.18%) of 358 FTMTS patients who underwent chest contouring surgery at our hospital between 2006 and 2018. Postoperative hematoma was examined retrospectively. The median time to the onset of hematoma was 7 (6-12) h after the initial surgery. The main blood vessels causing bleeding were those in the head-side skin flap region where visual confirmation was difficult and the perforator vessels from the pectoralis major muscle. Intraoperative bleeding and the operation time had a significant impact on the onset of postoperative hematoma. This is the first retrospective study that investigated the blood vessels and other factors contributing to postoperative hematoma development after chest wall contouring.

Laparoscopic Rectosigmoid Colon Vaginoplasty in Male-to-Female Transsexuals: Experience in Japan.

Intestinal vaginoplasty has several advantageous features, such as scarless surgery, low incidence of contraction of the reconstructed vagina, maintenance of vaginal depth, spontaneous mucus production, and a low rate of complications. Therefore, this technique is becoming popular in many countries. Following the global trend, the demand for intestinal vaginoplasty for transsexuals is also increasing in Japan. However, there are few reports on intestinal vaginoplasty in Japan. In this study, we examined the safety and effectiveness of rectosigmoid colon vaginoplasty in the Japanese population. We retrospectively surveyed 18 male-to-female transsexuals who underwent laparoscopic rectosigmoid colon vaginoplasty at the Okayama University Hospital Gender Center between October 2012 and December 2017. One patient had developed an anastomotic leak and 2 patients experienced vaginal prolapse, which needed revision surgery. Both adverse outcomes were comparable with those from previous studies. The anastomotic leak was managed adequately with conservative treatment. To avoid vaginal prolapse, it is important to decide the length of the rectosigmoid segment so that a pull on it does not cause it to become lax, while excessive stress on the feeder vessels is avoided. Based on our study, we concluded that rectosigmoid vaginoplasty was a reliable technique in the Japanese population.

Flap Combination Phalloplasty in Female-to-Male Transsexuals.

BACKGROUND: Although phalloplasty with a free radial forearm (RF) flap is the gold standard for sex reassignment surgery in female-to-male transsexuals, it can result in unsightly scars, lymphedema, and numbness of the hand. AIM: To introduce the concept of flap combination phalloplasty and its clinical application. METHODS: This is a retrospective chart review study of patients undergoing phalloplasty using various multiple flaps. Demographic data, surgical data, and outcomes were recorded. OUTCOMES: Of the 15 cases, 5 were urethral fistulas; 4 were venous thrombosis; 2 were urethral calculus; and 1 was a partial flap loss. RESULTS: 15 patients were included (age range 25-43 years, median 34 years). An RF flap and a deep inferior epigastric artery perforator flap combination were most frequently used. The median operative time for flap combination phalloplasty was 10.5 hours (range 6.5-12.5 hours). There was no total flap necrosis, but there was 1 case of partial flap loss. There were urethral fistulas in 5, venous thrombosis in 4, and urethral calculus in 2 cases. CLINICAL IMPLICATIONS: Flap combination phalloplasty will become the third option when both the RF flap and the anterolateral thigh pedicle flap are not useful. STRENGTH & LIMITATIONS: Flap combination phalloplasty is a complex operative procedure with a prolonged operative time, but it can provide more flap selection and reduce the morbidity at each donor site. Choosing from many different options can be beneficial to patients. CONCLUSION: Flap combination phalloplasty has a similar complication rate to other procedures and has advantages in terms of flexibility and less donor site morbidity; it may thus be an option when either the RF flap or the anterolateral thigh pedicle flap cannot be used. Namba Y, Watanabe T, Kimata Y. Flap Combination Phalloplasty in Female-to-Male Transsexuals. J Sex Med 2019;16:934-941.

Vaginoplasty with a Pudendal-groin Flap in Male-to-female Transsexuals.

Many vaginoplasty techniques have been introduced to improve the outcomes of sex reassignment surgery for male-to-female transsexuals. Some vaginoplasty patients still require additional skin grafts, making dilation mandatory to overcome shrinkage. We developed a new vaginoplasty method (called the "pudendal-groin flap") that uses pudendal-groin flaps. One of this procedure's advantages is that skin grafts are unnecessary, even for patients with small penises and scrotums. We introduce the procedure here and describe our evaluation of its utility. We retrospectively analyzed the cases of the 15 patients who underwent vaginoplasty using pudendal-groin flaps from May 2010 to January 2016 at our institution. We compared the complications as well as the functional and aesthetic outcomes with those of previous studies. The most common complication was bleeding, which occurred at the corpus spongiosum or while creating a new vaginal cavity. Bleeding can be reduced with more careful hemostasis and dissection. Aside from inadequate vaginal depth in one patient, the incidence of other complications, sexual intercourse, and aesthetic outcomes were acceptable. The pudendal- groin flap is thin and pliable and can create sufficient vaginal depth without skin grafts. The resulting scar is inconspicuous. Our findings suggest that vaginoplasty using the pudendal-groin flap method is feasible.

Dry Co-Digestion of Poultry Manure with Agriculture Wastes.

This study tested the effect on thermophilic and mesophilic digestion of poultry manure (PM) or treated poultry manure (TPM) by the addition of agriculture wastes (AWS) as a co-substrate under dry conditions. PM was co-digested with a mixture of AWS consisting of coconut waste, cassava waste, and coffee grounds. Results were increased methane content in biogas, with decreased ammonia accumulation and volatile acids. The highest performance occurred under mesophilic conditions, with a 63 and 41.3 % increase in methane production from addition of AWS to TPM (562 vs. 344 mL g VS(-1) from control) and PM (406 vs. 287 mL g VS(-1) from control), respectively. Thermophilic conditions showed lower performance than mesophilic conditions. Addition of AWS increased methane production by 150 and 69.6 % from PM (323.4 vs. 129 mL g VS(-1) from control) and TPM (297.6 vs. 175.5 mL g VS(-1) from control), respectively. In all experiments, 100 % acetate produced was degraded to methane. Maximum ammonia accumulation was lowered to 43.7 % by mixing of AWS (range 5.35-8.55 vs. 7.81-12.28 g N kg(-1) bed). The pH was held at 7.3-8.8, a range suitable for methanogenesis.

Phalloplasty with an innervated island pedicled anterolateral thigh flap in a female-to-male transsexual.

Since 2001, we have been performing phalloplasty with a radial forearm free flap as the flap of first choice in female-to-male transsexuals (FTMTS). In the present case, a 22-year-old FTMTS with a negative Allen test, we achieved good results by performing phalloplasty with an innervated island pedicled anterolateral thigh flap using the "tube within a tube" technique, in which the penis and urethra are constructed with a single flap. As compared to a forearm flap, use of an innervated island-pedicled flap may have the following advantages in phalloplasty: 1) no need for a microsurgical technique; 2) no scars at noticeable sites; 3) small functional loss in the flap donor area; 4) no sacrifice of major blood vessels. Thus, this technique seems to be a useful clinical alternative for phallic reconstruction.

Enhancement of methane production from co-digestion of chicken manure with agricultural wastes.

The potential for methane production from semi-solid chicken manure (CM) and mixture of agricultural wastes (AWS) in a co-digestion process has been experimentally evaluated at thermophilic and mesophilic temperatures. To the best of author(')s knowledge, it is the first time that CM is co-digested with mixture of AWS consisting of coconut waste, cassava waste, and coffee grounds. Two types of anaerobic digestion processes (AD process) were used, process 1 (P1) using fresh CM (FCM) and process 2 (P2) using treated CM (TCM), ammonia stripped CM, were conducted. Methane production in P1 was increased by 93% and 50% compared to control (no AWS added) with maximum methane production of 502 and 506 mL g(-1)VS obtained at 55°C and 35°C, respectively. Additionally, 42% increase in methane production was observed with maximum volume of 695 mL g(-1)VS comparing P2 test with P2 control under 55°C. Ammonia accumulation was reduced by 39% and 32% in P1 and P2 tests.

Thumb polydactyly with a floating ulnar thumb.

Thumb polydactyly is reported to be the most common congenital anomaly of the hand in Japan. The floating type is not particularly rare, accounting for 0.9 to 15% of all cases of thumb polydactyly. However, to the best of our knowledge, there has been only one case of thumb polydactyly with a floating ulnar thumb, reported by Onizuka. Herein, we report a case very similar to that reported by Onizuka. In our case, the vessels feeding the floating ulnar thumb branched from the superficial palmar arterial arch, and X-rays revealed triphalangism. In surgery, we not only reconstructed the morphology of the thumb, but also tried to preserve the sensation in the reconstructed thumb by transposing the digital nerve of the floating ulnar thumb to the radial thumb. In addition to thumb polydactyly, our case also showed hypoplasia of the thenar muscles.

Phalloplasty with an innervated island pedicled anterolateral thigh flap in a female-to-male transsexual.

Since 2001, we have been performing phalloplasty with a radial forearm free flap as the flap of first choice in female-to-male transsexuals (FTMTS). In the present case, a 22-year-old FTMTS with a negative Allen test, we achieved good results by performing phalloplasty with an innervated island pedicled anterolateral thigh flap using the "tube within a tube" technique, in which the penis and urethra are constructed with a single flap. As compared to a forearm flap, use of an innervated island-pedicled flap may have the following advantages in phalloplasty:1) no need for a microsurgical technique;2) no scars at noticeable sites;3) small functional loss in the flap donor area;4) no sacrifice of major blood vessels. Thus, this technique seems to be a useful clinical alternative for phallic reconstruction.

Negative pressure wound therapy incorporating early exercise therapy in hand surgery: bag-type negative pressure wound therapy.

In the postoperative treatment of hand surgery, it is important to start exercise therapy as early as possible. In conventional negative pressure wound therapy, the fingers are immobilized by the film dressing covering the wound and hand, thereby preventing sufficient rehabilitation. Here, we devised a bag-type negative pressure wound therapy that makes it possible to start finger exercises almost immediately, and we applied it to 4 patients:one each with hand burns, symmetrical peripheral gangrene, a crush injury accompanied by extensive skin defects and a fingertip degloving injury. The duration of the bag-type negative pressure wound therapy ranged from three to eight weeks, and good granulation was achieved, so that a skin graft was not required. In addition, particularly in the case of the fingertip degloving injury, good nail regeneration was achieved. Except for the case of symmetrical peripheral gangrene, a good range of joint motion with a percent total active motion (%TAM) of 94.7% or more was achieved. Our therapy was performed by inserting the hand into a sealing bag;sufficient exercise therapy was made possible by expanding the bag during rehabilitation.

[Improvement of therapeutic environment--effort to establish the medical center for GID in a general hospital].

Treatment for gender identity disorder (GID) should be done in cooperation with psychologist, gynecologist, urologist, plastic surgeon and extramural scholars as a team treatment. And if possible, it should be a comprehensive treatment with supports of a social worker, a coordinator and an expert nurse. The ethical committee for individual GID patient treatment has already dissolved according to the third edition of the guideline. We call the therapeutic team Okayama University Hospital Gender Center. It treats not only GID patients, but also gender associated diseases such as disorders of sex development (DSD). Unfortunately, there are not so many institutions which meet our conditions throughout the country. In the present circumstances we can't go along with their needs. So many GID patients go abroad and have Sex reassignment surgery (SRS). To solve this problem national insurance for SRS should be approved as soon as possible and many institutes should start GID treatment.

The utility of multidetector-row computed tomography angiography for evaluating perforators of fibular osteocutaneous flaps.

Multidetector-row computed tomography angiography (MDCTA) can be used to visualize small vessels and has been used to search for perforators in deep inferior epigastric artery perforator flaps and anterolateral thigh flaps. Fibula osteocutaneous flaps are often used for mandibular reconstruction, but questions remain about the reliability of these flaps and the variety of their perforators. Eight patients who were candidates for mandibular or pedal reconstruction with a fibula osteocutaneous flap were prospectively evaluated with MDCTA and Doppler sonography. We evaluated the number, position, and course of perforators with MDCTA. The perforators were classified, and intraoperative findings were compared with those of Doppler sonography and MDCTA. MDCTA accurately identified the perforators and showed a satisfactory concordance with intraoperative findings. The high spatial resolution of MDCTA allows the perforators' origin, course, and type to be precisely described. Eighteen vessels were identified with MDCTA, and on average, 2.3 vessels were identified in the leg of each patient. The rate of concordance with operative findings was 87.5% for MDCTA. With MDCTA, flap perforators can be accurately evaluated before surgery in a manner not possible with traditional angiography or Doppler sonography. Reliable perforators can be chosen, and detailed operative plans can be made.

Improved methane fermentation of chicken manure via ammonia removal by biogas recycle.

This study demonstrates methane fermentation that was carried out along with ammonia striping to avoid ammonia accumulation that significantly inhibited methane production. Ammonia was successfully removed by means of recycling of biogas followed by gas washing in sulfuric acid to capture ammonia, when chicken manure was anaerobically digested for 4 days at 55 degrees C and at an initial pH of 8-9. By using this method, 80% of total nitrogen in chicken manure was converted to ammonia and 82% of the produced ammonia was removed. A bench scale reactor equipped with an ammonia-stripping unit for methane production from chicken manure was developed and operated in repeated batch mode. At an initial pH of 8 and at 55 degrees C, 195 and 157 ml g-VS(-1) of methane was successfully produced from the treated chicken manure and the mixture of treated chicken manure and raw chicken manure in the ratio of 1:1, respectively. In this method, ammonia concentration was maintained at a level lower than 2g-N kg-wet sludge(-1) in the reactor.

Mastectomy in female-to-male transsexuals.

The first operative procedure in sex reassignment surgery (SRS) for female-to-male transsexuals (FTMTS) is mastectomy. This procedure includes the removal of mammary tissue, removal of excess skin, and reduction and proper repositioning of the nipple and areola complex. We have performed mastectomies in over 120 patients since January 2001 and want to describe the operative procedures we have developed. We classified our patients into 3 groups according to the patient's breast volume and the degree of ptosis, and we selected the operative procedure that was suitable for each group. At present all costs for SRS are assumed by the patient in Japan. If the FTMTS patient undergoes the entire series of SRS operations, he has to pay more than 3,000,000 yen. Thus the surgeon should select the proper operative procedure so that the patient can avoid unnecessary additional operations. We describe herein the techniques and the strategy for performing mastectomy in FTMTS.