Modified Internal Pudendal Artery Perforator Flap Interposition for Rectovaginal Fistula.

IMPORTANCE: Rectovaginal fistula (RVF) is a challenging condition associated with recurrences and significant functional impairment. OBJECTIVES: The internal pudendal artery perforator (IPAP) flap has become a viable option for reconstructing the vagina and perineal regions. This study aims to introduce a modified technique of IPAP flap interposition and evaluate its postoperative outcomes in the treatment of low RVF. STUDY DESIGN: Sixteen patients with RVF who underwent modified IPAP flap interposition between 2016 and 2021 were retrospectively enrolled. Recurrence rate, the satisfaction of vulvar appearance (Visual Analog Scale), and quality of sexual life (Female Sexual Function Index score) were followed up and analyzed. RESULTS: All patients presented with low fistula with a mean diameter of 8.3 mm. The mean width and length of the IPAP flaps were 3.8 and 6.2 cm, respectively. The mean follow-up period was 14.1 months. All patients achieved successful healing without recurrence. High satisfaction was reported for the cosmetic effect of the vulva with a mean Visual Analog Scale score of 8.4. The proportion of female sexual disorder exhibited a statistically significant reduction, decreasing from 100% preoperatively to 38% after surgery (P < 0.05). CONCLUSIONS: The modified IPAP flap interposition is a reliable and safe option for repairing low RVF, with high success rates and minimal donor site morbidity. Moreover, this procedure provides a suitable volume flap and preserves the vaginal physiological environment, which benefits postoperative sexual function.

The Buried Guide Suture Method: A Novel Technique to Correct Traumatic Facial Dimples.

SUMMARY: Facial dimpling, frequently occurring after blunt trauma, presents as soft-tissue depression, which is particularly apparent during facial expression. The displacement of subcutaneous tissue can be detected and measured by high-frequency ultrasound. Limited surgical methods have been applied in these closed-injury cases. Repositioning the subcutaneous tissue without incisions on unscarred skin is challenging. The authors propose a novel three-dimensional technique to suture and fix the subcutaneous tissue at a distance through a concealed incision. The buried guide suture method was used in the treatment of 22 patients with traumatic facial dimples on the cheek. All patients showed great improvement in their depressed deformity with minor complications. This technique provides an option to correct soft-tissue depression without leaving a visible scar, especially for mimetic rupture caused by blunt trauma.

Transvaginal Posterior Levatorplasty Combined with Perineoplasty: An Effective Surgical Method for Vaginal Rejuvenation.

BACKGROUND: Recently, gynecological cosmetic surgery and rejuvenation surgery have become increasingly popular, with a surging vaginal surgery demand for female vaginal laxity. However, follow-up data on the effectiveness of such procedures remain limited. OBJECTIVE: We conducted a retrospective study aimed to investigate the effects of transvaginal posterior levatorplasty combined with perineoplasty on vaginal rejuvenation. METHODS: Forty-five patients, who underwent transvaginal posterior levatorplasty combined with perineoplasty between July 2020 and May 2022, were included. Patient characteristics before operation, at baseline, 3, 6, and 12 months postoperatively, questionnaires on patient symptoms, quality of life, and sexual function, including Vaginal Laxity Questionnaire (VLQ) and Female Sexual Function Index (FSFI) were evaluated. Pelvic ultrasound imaging was performed preoperatively and 3 months postoperatively. RESULTS: Mean vaginal capacity index and Vaginal laxity scores were different at baseline, 6, and 12 months postoperatively (p<0.01). Female sexual function including libido, sexual arousal, lubrication, orgasm, sexual satisfaction and pain were significantly improved (preoperative: 21.68±4.15; 6 months postoperatively: 26.88±2.44; 1 year postoperatively: 29.97±2.10; p<0.01). The symptoms of stress urinary incontinence (SUI) and recurrent vaginitis were improved in 78.6% and 90.5% of the patients, respectively. In pelvic floor ultrasound, retrovesical angle (RVA), urethral rotation angle (URA), levator hiatus (LH), and bladder neck distance (BND) were significantly different preoperatively and at 3 months postoperatively (p<0.01). Overall satisfaction was 93.3% at 12 months postoperatively. CONCLUSIONS: Transvaginal posterior levatorplasty combined with perineoplasty is effective for the improvement of patient symptoms, quality of life, sexual function, SUI, and postnatal constipation. Further research on the underlying mechanism is required. LEVEL OF EVIDENCE: Therapeutic, III.

Lymphatic Pathways on Indocyanine Green Lymphography in Patients with Labia Minora Hypertrophy.

BACKGROUND: Labia minora hypertrophy (LH) is a growing aesthetic concern, yet its etiology and local lymphatic anatomy remain unclear. This study aimed to use indocyanine green (ICG) lymphography to investigate evidence of lymphedema in LH and clarify the anatomy of lymph vessels from labia minora. METHODS: Thirty-five patients with LH underwent preoperative ICG lymphography of their bilateral labia minora. The study reviewed demographic, ICG imaging, and measurement data to identify the characteristics of the superficial lymphatic anatomy in labia minora. RESULTS: The ICG lymphography findings revealed that 97.1% of the observed patterns were linear, and 2.9% were dermal backflow patterns. Further analysis of the linear patterns revealed the presence of three main superficial pathways originating from the labia minora and connecting to the labia majora and clitoral hood. These pathways were identified as the superior, median, and inferior channels. Based on the observed lymphatic mapping in the labia minora, three types were classified: type 1 (Superior + Inferior channels) accounted for 75.0% (51 sides), type 2 (Median + Inferior channels) accounted for 8.8% (6 sides), and type 3 (Superior + Median + Inferior channels) accounted for 16.2% (11 sides). CONCLUSIONS: The study demonstrates that ICG lymphography enables clear visualization of superficial lymph flow from labia minora. It also suggests that lymphedema is not a common pathologic feature of LH. Understanding the lymphatic anatomy of the labia minora can provide valuable guidance for surgical interventions involving the female external genitalia.

The 50 most cited articles and science mapping analysis of vaginal tightening.

INTRODUCTION AND HYPOTHESIS: The study was aimed at exploring the 50 most cited articles related to vaginal tightening. METHODS: The papers were searched through the Thomson Reuters Web of Science on 30 July 2022, and were ranked by the total number of citations. The included articles were analyzed for author, journal, country, number of citations, keywords, subject matter, and level of evidence. The search output was also imported into VOSviewer. RESULTS: The 50 most cited articles were cited a combined total of 2,558 times. The papers were published between 1990 and 2020, of which 86% were published between 2010 and 2020. They included 38 original articles, 8 reviews, 3 editorial articles, and 1 letter. Most articles were published in gynecology-related journals (n=30, 60%). The articles covered a wide range of topics, the most common being laser/radiofrequency treatment, vaginal tightening procedures, and urinary incontinence. The majority presented findings supported by level IV or V evidence. Through co-occurrence analysis, high-frequency words and countries were displayed well. CONCLUSIONS: The study shed light on frequently read articles and influential topics about vaginal tightening. The highly cited literature mainly focused on laser or radiofrequency treatments and gynecologists currently dominate the highly cited literature on vaginal tightening. The articles related to surgical treatments are low in number and evidence level so far. The co-occurrence analysis reveals the hot research content and active countries in the field. In general, the study provides useful evidence for future research and educational materials.

Trend of Academic Productivity in Plastic Surgery and the Impact of COVID-19: A Bibliometric Analysis.

BACKGROUND: Plastic surgery has grown rapidly over the past decade, with increasing scientific output. The emergence of coronavirus disease 2019 (COVID-19) has a considerable impact on plastic surgery. OBJECTIVE: To identify trends in published literature in plastic surgery from 2011 to 2021. To explore the impact of COVID-19 on scientific research output through bibliometric analysis methods. METHODS: Web of Science was searched by authors on December 23, 2021. Published papers about plastic surgery over the last decade were analyzed. The search output was imported into VOSviewer for science mapping. RESULTS: The actual number of papers related to plastic surgery during the COVID-19 period was higher than expected one. For scientific outputs in plastic surgery, keywords about surgical practice had a high frequency. "Reconstruction," "effect," "flap," "tissue," "defect," "model" maintained a high level of heat before and after COVID-19. The heat of "risk," "complication," "review," "infection," "cohort," and "meta-analysis" increased after the outbreak of COVID-19. The international collaboration showed an upward trend despite the impact of COVID-19. From the perspective of the volume of plastic surgery publications, some journals had a more positive performance compared to the pre-epidemic period. The proportion of original articles decreased after the spread of COVID-19 from 70.26% to 63.84%. CONCLUSION: Although the COVID-19 has a profound impact on the healthcare industry, the bibliographic data reveals an increasing scientific output in the field of plastic surgery over time. For plastic surgery, high-frequency terms, research hotspots, popular journals, article types, and international collaboration have changed under the influence of COVID-19.

Sub-regional skin grafting for perineal resurfacing after excision of superficial vulvar tumors: An excellent method to achieve an aesthetically pleasing appearance.

OBJECTIVE: To investigate the effect of sub-regional split-thickness skin grafting in perineal resurfacing. METHODS: A single-center retrospective study was conducted in the Genital Plastic Surgery Center. Detailed clinical data of 14 consecutive patients who underwent split-thickness skin grafting after vulvar tumor resection from February 2013 to June 2022 were analyzed. Clinical data, postoperative photographs, scoring of vulvar appearance, and questionnaire results of the Female Sexual Function Index before and after surgery were analyzed. RESULTS: The patients had sub-regional split-thickness skin grafting ranging from 7 × 8 cm to 11 × 12 cm (88.86 ± 24.99 cm2 ). After a follow-up of 8.21 ± 2.22 months (mean ± SD), all patients had a three-dimensional and aesthetically pleasing vulva and high scoring of vulvar appearance (mean ± SD, 4.43 ± 0.65). All patients had good healing of both the recipient and donor sites without major complications. Only one patient had minor dehiscence in the perineal region and recovered soon after proper treatment. The scores of the Female Sexual Function Index were significantly improved after surgery. Among the included domains, scores of "desire," "arousal," "orgasm" and "satisfaction" increased significantly after surgery (p value <0.05). CONCLUSIONS: Sub-regional split-thickness skin grafting could achieve excellent cosmetic outcomes with few complications in perineal reconstruction after the excision of superficial vulvar tumors. It can provide an aesthetically pleasing appearance in the vulvar region and improve female sexual function to some extent. In general, sub-regional split-thickness skin grafting could be a recommended reconstructive option to repair vulvar defects.

Circumferential full-thickness skin grafting: An excellent method for the treatment of short penile skin in adult men.

Objective: Short penile skin due to excessive circumcision is a complex condition requiring surgical care. The study aims to investigate the effect of full-thickness skin grafting (FTSG) in treating short penile skin. Methods: A retrospective analysis was performed on 24 patients with insufficient penile skin. The included patients underwent full-thickness skin grafting from the scrotum and the groin region in the Genital Plastic Surgery Center between February 2014 and September 2021. Morphology of the penis, length of the penis, complication, and donor area healing status was observed by the authors. Additionally, the International Index of Erectile Function Questionnaire (IIEF-5) and the patient's evaluation of penile appearance were investigated. Results: An aesthetically pleasing appearance of the penis was obtained by FTSG in 24 patients. The length of penis was improved after surgery (5.70 cm ± 1.24 cm vs. 6.05 cm ± 1.33 cm, P value < 0.05). All patients had good healing of the penile area without serious complications. Only 2 cases showed minor partial necrosis and recovered soon after proper treatment. A high patient's evaluation of penile appearance was received (4.08 ± 0.71, mean ± SD) and the scores of IIEF-5 increased significantly after surgery (18.38 ± 2.24 vs. 21.08 ± 1.79, P-value < 0.05). Conclusions: FTSG from the scrotum and inguinal skin provides good aesthetic and functional results for treating short penile skin. FTSG, particularly the scrotum-derived skin graft, offers a great supplement to penile skin. It could be suggested as a promising method of treating insufficient penile skin, which meets both functional and aesthetic needs.

Preliminary Exploration of a New Clitoral Hood Classification System and Treatment Strategy.

BACKGROUND: Increasing attention has been given to clitoral hoods in recent years, but few studies have been conducted on the classification and treatment strategies of clitoral hood hypertrophy. The purpose of this article is to introduce a new system of clitoral hood classification based on relevant anatomy and make recommendations for clitoral hood reduction. METHODS: The clitoral hood region is divided into the central zone (zone C) and the lateral zone (zone L). According to the anatomical characteristics of each zone, patients can be divided into 5 types: standard form, central hypertrophy, lateral hypertrophy, composite hypertrophy and special type. Central hypertrophy is further divided into wide and long clitoral hoods, and horizontal and vertical redundancy are addressed using bilateral clitoral hood triangular skin resection and inverted horizontal V-shaped skin resection, respectively. Lateral hypertrophy can be treated with vertically oriented excision. Composite hypertrophy is corrected by combining these methods to remove redundant tissue depending on the situation. RESULTS: 1135 patients were classified according to the new classification system and 789 participants were given corresponding treatment measures. Thirty-four patients (4.3%) experienced complications, and 15 (1.9%) underwent revision surgery. Six months after the procedure, clitoral hood images improved significantly without paresthesia, and the overall satisfaction rate of the patients regarding clitoral hood reduction was 95.7%. CONCLUSIONS: The clitoral prepuce is an important part of the aesthetic unit of female vulva. The new clitoral hood classification strategy systematically summarizes the anatomical characteristics of the clitoral hood and clearly makes recommendations for surgical options. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Trilobal Methods for Composite Reduction Labiaplasty.

BACKGROUND: It is difficult to plan a simple and effective surgical strategy for patients with horizontal and vertical redundant tissue of the labia minora and clitoral hood redundancy. A single edge resection or wedge resection labiaplasty with clitoral hood reduction that simultaneously resolves these three issues has yet to be reported. This study investigated the clinical effects and safety of trilobal labiaplasty via a composite incision. METHODS: The single-center, retrospective, observational study included data from patients with hypertrophy of the labia minora and clitoral hood who underwent trilobal labiaplasty. RESULTS: Altogether, 136 patients (average age: 31.6 ± 8.82 years; range: 21-53 years; 224 sides) sought surgery for aesthetic (39/136, 28.7%), functional (17/136, 12.5%), or both reasons (80/136, 58.8%). Overall, 134 patients (134/136, 98.5%) were followed up for 3 months. No serious complications or malformations occurred. Three patients (2.2%) underwent secondary repair surgery due to incomplete bilateral symmetry, 122 (91.0%) scored ≥ 21 points on the Female Genital Self-Image Scale, 107 (91.5%) were satisfied with the cosmetic outcomes, and 93 (95.9%) were satisfied with the functional improvement. CONCLUSIONS: Trilobal labiaplasty performed via a composite incision using edge and wedge labiaplasty to adjust horizontal and vertical hypertrophy of the labia minora and remove lateral folds of the clitoris is a safe and effective method to improve the appearance and rearrange the position of the clitoral hood and clitoral frenulum while preserving the fine structure of the surrounding tissue. This method results in few complications and high functional and aesthetic satisfaction rates. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Quantitative analysis of the labia minora morphology in 400 Chinese women: A new method for assessing the shape of the labia minora.

Purpose: To investigate the shape of labia minora in Chinese adult women. Methods: Women who visited the Genital Plastic Surgery Center from January 2021 to February 2022 were included and the vulvar regions were photographed. The shape of the labia minora was converted into quantifiable values [left side line segment 1-9 (L1-L9 values) and right side line segment 1-9 (R1-R9 values)]. The 400 enrolled patients were grouped by age, parity, and the types of vulvar surgeries they planned to undergo. Results: After a graphic-to-digital and digital-to-graphic conversion, the simulated average image of the labia minora in Chinese adult women was constructed based on the mean values of L1-L9 and R1-R9. Comparing the values of Ln and Rn in the four age groups revealed that the mean values of Ln and Rn gradually decreased with age, but only two subgroups showed statistically significant differences (P-value <0.05). When the patients were stratified according to the number of births and whether labiaplasty was planned to perform, there were no significant differences among all groups (P-value >0.05). Conclusion: To measure and evaluate the labia minora, a new assessing method was used. It is an innovative attempt to transform the simple rough description of the shape of the labia minora into more precise data reflecting the shape features. It allows the comparison of labia minora shape between individuals by comparing quantifiable values. Besides, the average shape of labia minora in Chinese adult women was provided visually. Factors including age, parity, and whether the patient planned to undergo labiaplasty were not significantly associated with the shape of the labia minora.

Efficacy of CO2 laser treatment in postmenopausal women with vulvovaginal atrophy: A meta-analysis.

OBJECTIVE: To explore the efficacy of CO2  laser treatment in postmenopausal women with vulvovaginal atrophy. METHOD: PubMed, Embase, Cochrane Library and Web of Science were searched to June 9, 2020. Prospective studies on the efficacy of CO2  laser treatment were included. Two researchers independently reviewed articles and extracted data. Heterogeneity test was conducted for each outcome indicator. Sensitivity analysis was performed in all models. RESULTS: Twelve articles including 459 participants were enrolled. Compared with baseline, vaginal health indeices (VHIs) were significantly higher at the 1-, 3-, 6-, and 12-month follow ups (P < 0.001). For VVA severity, the visual analog scale scores for vaginal dryness at 1-, 3-, 6-, and 12-month follow-ups (P < 0.050), vaginal burning, itching, and dysuria at 1-month follow up (P < 0.001), and dyspareunia at 1-, 3-, 6-, and 12-month follow-ups (P < 0.001) were all significantly lower. For FSFI, total scores at 1-, 3-, 6-, and 12-month follow ups (P < 0.001), and the scores in desire, arousal, lubrication, orgasm, satisfaction, and pain at 1-month follow up (P < 0.050) were all significantly higher. For quality of life, the PCS12 and MCS12 scores were all significantly higher (P < 0.050) at the 1-month follow up. CONCLUSION: CO2  laser treatment may be effective for postmenopausal women with VVA symptoms in improving quality of life and sexual function.

Simultaneous SERS detection of illegal food additives rhodamine B and basic orange II based on Au nanorod-incorporated melamine foam.

In food safety assessment, surface-enhanced Raman spectroscopy (SERS) is a novel detection method with the advantages of being fast, easy, and of high sensitivity. However, many SERS substrate synthesis methods are complex, and there are only a few studies on the simultaneous detection of multiple substances. In this study, a new, simple, low-cost SERS substrate was synthesised for the first time to simultaneously detect illegal food additives rhodamine B and basic orange II in chilli products. A lightweight, porous, and low-cost material of melamine foam (MF) was employed as the SERS synthesis template. The substrate's SERS effect on, and sensitivity to, rhodamine B and basic orange II were demonstrated. The molecular vibration and SERS enhancement mechanisms of the two target molecules were analysed by density functional theory (DFT) calculations. The results reveal that this fabricated substrate has great application potential for the supervision and testing industry.

A New Concept for Central Wedge Resection in Labiaplasty.

OBJECTIVE: The aim of the study was to develop a new concept for central wedge resection to improve surgical results. Currently, the most common postoperative complications of the regular central wedge (RV) resection technique are wound dehiscence and scar contracture. METHODS: A case-control study was applied to randomly divide 119 patients with labia minora hypertrophy deformities into 2 groups: new central wedge (NV) (n = 57) and RV (n = 62). All patients underwent the corresponding corrective surgery to repair the deformity. During the NV procedure, we changed the direction of the scalpel to form 2 inclined sections and sutured these sections together to achieve nonparallel closure lines. The patients in the 2 groups were followed up at 1 and 6 months postoperatively. We described the details of this method and evaluated the treatment outcomes of the 2 groups. RESULTS: Patient age, labia minora width, and procedure time were not significantly different between the 2 groups (p > 0.05). However, the visual analog scale (VAS) scores in the 2 groups were significantly different (p < 0.05). Two patients in the NV group were somewhat dissatisfied because of lymphoedema and asymmetry; 6 patients in the RV group expressed dissatisfaction with scarring, healing complications, and asymmetry. A minor corrective operation was performed for asymmetry, and the dehiscence healed spontaneously. The patient with edema is still being followed up. CONCLUSION: The surgical method we introduced was indicated to be a simple and effective procedure that avoided wound dehiscence and scar contracture, which are common with the regular approach.

EMLP: short-term gas load forecasting based on ensemble multilayer perceptron with adaptive weight correction.

This paper tackles a recent challenge in smart city that how to improve the accuracy of short-term natural gas load forecasting. Existing works on natural gas forecasting mostly reply on a combined forecasting model by simply integrating several single-forecasting models. However, due to the existence of redundant single-forecasting models, these works may not attain a higher prediction accuracy. To address the problem, we design a new natural gas load forecasting scheme based on ensemble multilayer perceptron (EMLP) with adaptive weight correction. Our method firstly normalizes multi-source data as original data set, which is further segmented by a window model. Then, the abnormal data is removed and subsequently interpolated to form a complete normalized data set. Furthermore, we integrate a series of multilayer perceptron (MLP) network to construct an ensemble forecasting model. An adaptive weight correction function is introduced to dynamically modify the weight of the previous predicted result. Since the correction function can match well the volatility characteristics of load data, the prediction accuracy is significantly improved. Extensive experiments demonstrate that our method outperforms existing state-of-the-art load forecasting schemes in terms of the prediction accuracy and stability.

A preliminary observational study on the vascular, nerve, and lymphatic anatomy and histology of the labia minora from cadaveric and surgical samples.

INTRODUCTION AND HYPOTHESIS: To better understand details of the fine anatomy of the labia minora, present images of the vascular anatomy and characterize the nerve and lymphatic distribution of the labia minora. METHODS: Two fixed and five fresh cadaveric specimens were perfused and dissected, and the vascular network was photographed. Labia minora samples, prepared from cadavers, and tissue resulting from labia reduction surgery underwent hematoxylin and eosin staining and S100 and D2-40 immunohistochemical staining. RESULTS: Arteries emanated from the base to the edge of the labia minora, where there was a larger feeding artery, and the arteries were anastomosed. The veins formed anastomotic branches in the same direction as the edge of the labia minora. Arteries and veins that accessed the labia minora were successfully perfused at the same time with no obvious association. Sensory nerve endings were abundant, mostly larger with myelinated nerve trunks and Schwann cells in the central area with suggested neurovascular associations and smaller with no obvious aggregation at the edge. The medial area had 23.63 ± 11.82 nerves/view, the lateral area 21.30 ± 11.49 nerves/view (P > 0.05). The thickest nerve bundle was 3.16 ± 1.41 mm from the medial epidermis and 3.13 ± 1.47 mm from the lateral epidermis. Lymphatic vessels showed no obvious regional distribution. Labia minora were 21.77 ± 5.69 mm wide with 252.87 ± 63.01 lymphatic vessels at 3.67 ± 1.61/mm2 density. The shortest inner diameter of dilated lymphatic vessels was 161.09 ± 49.99 µm. CONCLUSION: A larger feeding artery exists in the labia minora, which should be noticed in the pre-surgery design of labiaplasty. No difference was observed in the nerve distribution between the medial and lateral sides. Lymphedema might not be the cause of labial hypertrophy.

Management of duodenal atresia associated with situs inversus abdominus: A case report.

RATIONALE: Duodenal atresia in association with situs inversus abdominus is extremely rare. Care should be taken when selecting appropriate surgical methods, and caution should be exercised during the surgery to avoid misdiagnosis and mistreatment. With prompt recognition of the condition, the surgical procedure should be performed in a timely manner to achieve positive results. PATIENT CONCERNS: A newborn affected by situs inversus abdominus associated with duodenal atresia, midgut malrotation, and volvulus. DIAGNOSIS: Congenital duodenal atresia with situs inversus abdominis. INTERVENTIONS: Diamond-shaped duodenoduodenostomy with appendectomy was performed, with the release of Ladd band and correction of the malrotation. OUTCOMES: The baby boy is thriving well with no abdominal complaints at 4 years of surgical follow-up. LESSONS: Although several theories are put forward to clarify this matter, the proper cause of duodenal atresia is not well defined. Clinical symptoms and examinations can assist diagnosis, the definitive cause should be ascertained by surgical approach. And the operating surgeon must be aware of the "mirror anatomy" to prevent unnecessary injuries. Additionally, long-term prognosis for duodenal atresia are very good, therefore, careful attention in postoperative management are important in such a case.

L-Shaped Incision in Composite Reduction Labiaplasty.

Labia minora hypertrophy, in combination with clitoral hood protrusion, is a common deformity encountered in clinic practice and should be treated as a compound entity. Most targeted surgical procedures are too complex to understand and master. Herein, we introduce a relatively simple method to correct this deformity. In this study, we retrospectively review our experience treating patients with deformity of labia minora hypertrophy combined with clitoral hood protrusion between January 2017 and November 2019. All patients received correction surgery to repair the complex deformity. During the procedures, we divided the complex operation into two parts: clitoral hood reduction using L-shaped incision and then labiaplasty using L-shaped edge resection. We describe the details of the method step-by-step and evaluate the treatment outcomes. A total of 38 sides (14 bilateral procedures and 10 unilateral procedures) of clitoral hood reduction and labiaplasty were performed. There were no wound healing complications in any cases. One patient had a secondary corrective operation for obvious asymmetry of bilateral labia minora. Ultimately, all the patients were satisfied with the cosmetic appearance and did not have complaints. The surgical procedure we describe proved to be an effective, simple method for dealing with the complex situation of hypertrophy of labia minora combined with clitoral hood protrusion. Subsequent L-shaped edge resection of labiaplasty is appropriate for individuals with darker skin, in particular.Level of evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 . Genital Surgery.

Autologous Buccal Micro-Mucosa Free Graft combined with Posterior Scrotal Flap Transfer for Vaginoplasty in Male-To-Female Transsexuals: A Pilot Study.

BACKGROUND: The inverted peno-scrotal flap method is considered the standard method of vaginoplasty in male-to-female genital reassignment surgery. Though with numerous advantages, the method has its limitations regarding skin texture, lack of inherent lubrication, and that the tissues for creating the labia depend on the amount of tissues remaining after vaginoplasty. Our purpose was to describe the procedure and outcome of vaginoplasty applying a new technique: autologous buccal micro-mucosa free graft combined with posterior scrotal flap transfer, which could solve some of the problems the previous methods had. METHODS: Nine male-to-female transsexual patients received our new method of vaginoplasty from July 2010-October 2015. We described the details of the surgical procedure and evaluated the long-term anatomical and functional outcomes. RESULTS: In a mean clinical follow-up period of 25.3 months and phone interview follow-up of 50.3 months, we observed that the neovaginas in the nine cases were all of sufficient volume, lined with mucosa, with natural mucosal discharge. The oral donor sites resulted in no visible scars or malfunction. Eight patients experienced uneventful postoperative periods, while one patient suffered from scrotal flap prolapse. All the patients were sexually active and reported sexual satisfaction, with no need of lubrication. CONCLUSION: The reported technique achieves the outcomes of creating a neovagina of sufficient volume, without serious stenosis in long-term follow-up. The neovagina is lined with mucosa and has appropriate lubrication as well as good sexual sensation. The reported method is easy and economical to perform and retains enough tissues for vulvoplasty to achieve a superior cosmetic appearance, with rare risk of complications and donor area malfunction. Additionally, this technique is feasible and advantageous to the patients who have insufficient peno-scrotal skin for neovaginal lining as well as those with unfavorable previous vaginoplasty. All of these indicate that this technique is a promising option for vaginoplasty in male-to-female transsexual surgery. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Scrotal-Septal Fasciocutaneous Flap Used as a Multifunctional Coverage for Prior Failed Hypospadias Repair.

OBJECTIVES: The study aims to report the method and outcome of using scrotal-septal fasciocutaneous flap as a multifunctional coverage for prior failed hypospadias repair. METHODS: From January 2014 to June 2015, 18 hypospadias patients who have undergone repeated failed surgeries were enrolled. Their penile skin, urethral plate and dartos fascia are not enough to reconstruct the urethra, but have well-developed scrota. We performed urethroplasty by buccal mucosa free grafting and tubularized anastomosis 6 months after the urethroplasty. Then, scrotal-septal fasciocutaneous flap was used to be a multifunctional coverage on the surface of anastomotic urethra, which was a waterproof layer and cutaneous coverage. RESULTS: The skin flaps survived and the incisions healed in 18 patients. No fistula and stricture occurred. The scar of donor site seemed like a new scrotal raphe. The flap can slip slightly along with the preputial movement and retain the original sense of touch. All patients were followed up at 1 and 6 months by telephone or in person and gained good recoveries. CONCLUSION: Scrotal-septal fasciocutaneous flap, including sufficient fascia tissue, reliable blood supply and skin coverage, is a good choice for the coverage of anastomotic urethra as both the waterproof layer and skin coverage, especially for hypospadias patients who have undergone several failed operations.