The 12^th edition

In some patient  that  have long  penis we will try  to use  the  penile  flap to  be  the  anterior  vaginal wall. To  avoid  the graft contractionb at the  anterior vaginal  wall and  to  gain the  benefit  of flap elasticity, the new design of penile flap has been deveioped. It take  about 1 year  to get  this  setting prior to  failure of  other 2 setting.  The anterior penile flap is  separate to make  the long labia minor and  the  distal end turn to  construct  the vaginal  wall next to  the  urethral opening. In  this  setting the  urethal opening is quite stable and  the vaginal opening is wider and more elastig. So  the  dilation and sexual  intercourse will be  much easier.

The 2^nd version of the 12nd  edition

As we set  the  urethal flap  and  graft  in the new design, we modify  the  technique of tissure  setting. We  interpose  the urethal opening and  the distal penile flap with  the urethal graft. Therefore  the opening of valva  consist of mucosal tissue  that have slippery surface which facilitate  the dilation and insertion

MTF surgery the 11^th   edition

The  development  of edition  11th  is to correct  the problem   in case  of  short penis and  it  is  the  development  from  the  9^thedition . We can make  longer labial lip to  be more pimilar to  the  congenital labia.

The lining of vagina consisted of scrotal graft making  the anterior wall from the opening of valva  and  long scrotal flap a and graft to make  posterior wall. The  posterior  flap is  raised as parineal artery- pedicle flap , so  the  circulation to the  distal end  come from the 2 arteries from the groove of penile crus. As a result , the skin of the beginning of  posterior flaps can be cut medially to make  a space of  labia minor, then we can make  the  end  of labia come  closer  to be more similar to the female anatomy . Any way now  we cannot make  the true posterior fouchette because  of  the shortness  of  the tissue.

All of penile  skin  is  used  just for  the  labia minor reconstruction , the settit  of  upper half of labia  is the same  as the 9^th edition but  for the  lower half, instead of hanging from the  anterior vaginal  wall, the labia attach  the side wall of  vagina  by 2 special designflap …from the posterior flap.

The developed pedicle posterior is  the  key to make the longer labial lip to  make  more esthitic vagina.

The 2^nd version of  the 11st  edition

Since  there  is a lot  of change  happened in the  11st edition  so  a lot of  minor adjustment has been created.  At  the first time ,   we use a part of the posterior  flap to line  the  beginning of  anterior flap but since we donot  have a lot of tissue, the opening of  vagina is too  norrow  and  cause  the problem of  dilatiion. Then we use  the  scrotal graft more  to  the  beginning of  ant wall  but the result  of   graft contraction result  the  narrowing of  the  vg opening and pulling of  the urethal.

So now we modify  the  setting  of  the  urethal mocosa . the uretral tube is  separated in a new designed, getting  more tissue  to  the valva area and  less  tissue  to  the critoris  area. So  the  crus  of  critoris come closer  together to be  more natural and most mucosal  tissue move  to postrior  to  be the  beginning of  anterior vaginal wall. Since  the  tissue  is  a long flap, so  the   graft  contaction will  not  effect  the  urethal and  since  the  lining is mucosal tissue  that is  more similar to  female  vagina.the surface of  the  anterior wall  is   slipper and  natural, so  it  facilitate the sexual intecouse  and  dilation. The urethae flap can be  effectively used to   correct the problem of narrowingof valva.Moreover  at  the side of urethal flap, we can add the  urethral mucosal graft in the  new design that  can make  the  valva wider and  correct  the  problem of  inadequate  tissue at the anterior wall

This  setting  of urethrae is  not new. It   has been done  in europe for  more  than 20 years  but  indifferent  setting  from ours. The result is  excellent  for  functional vagina because  it make  the sexual  intercourse and dilation easier. Anyway some one  will  notice  the  redness  of  the urethrae  at  the  beginning of anterior  vaginal wall and  look  not esthetic. But  after  4 0r 5  monthes,  the  redness  will  turn to  be  pink color and  look  more  natural.

The risk  of  this  setting is  the separation of  the wound of labia minor if  the penis  is  too short an is  not easy  in the  setting for the primary colon vaginoplasty.

The 10^th edition

For  the 9^th we designed to  make  functional vagina but it    suit  to   asian people  that  have  less hair. For  the 10^th edition,  we put  almost total  graft to  the  vaginal  wall to  get rid  of  hairs, The posterior  wall  is  very short  and  need  no vascularised. It has less feeling, less elasticity but get more benefit  in the hair free vagina.

Since we  do not  need the tissue  for  anterior vaginal wall, so  we can use  the  penile flap  to  make  a longer labia to cover  the side of vaginal opening.

The problem of the 10^th is the contraction of  the  graft  that stay beneath the  urethral opening , the contracted graft pull down  th e opening of urethane to  the  Vg cavity. In some  cases the opening  turn to  inside of vagina .

The 9^th edition 

In this edition  we study more on, the  vascular  and  nerve supply  of  the scrotal flap to  make  the  posterior  flap. We preserve and meticulous dissected the flap to  make  more senstive  and survived posterior flap .The posterior flap will be  thicker  and  perineal vss is dissected to the flap until  the separation of deep artery and  dorsal  artery. After the  artery is  brought  togeter  to  the flap, less congestion ,less hematoma  and less end necrosis  occur, Anyway  this  type  of  dissection cause  more intra op bleeding. As we got the  good survival of  flap,we can modify  the  flap in  the  setting of  edition 11st and  12nd.

We concentrate more  on flap setting, the posterior flap is  set deeply to  the longitudinal layer of  the rectum. The anterior flap is  fixed to  the posterior bladder wall and prosthetic capsule. The labia minor is more dissected and  set  in the new style  of 3 point setting. We  separate  the midline of  anterior flap  to make  a long  midline  cleft and fix to  the prostate to  get  the  longer  and  more complete structure of labia minor. Any way  the  labia minor  end at  the  anterior  vaginal  wall  and does not  cover on  the side  of  vaginal opening.

The  penile  flap is  meticulous dissected to  make  the  very narrow pedicle  and  the narrow  clitoral  hood  can be  fixed to  the  pubic symphisis to  make  a permanent hood. The tunica albuginia get a new  design to act as  the  port of clitoral base to  make  it  stay  in midline.

The 9^th is  one  of a perfect design  that  get  the concept  from  the  house  building and foundation. We set  the foundation first  to  the  strong foundation area as periostium…..the  uretral is  set first instead of  last ,then the valva , the hood  and lateral wall of labia minor was set  to the  priosteum and stump of penile  crus, Then   the pile is  complete , other structure  will  be attached  to  the pile.

With this concept  we  can control  the external appearance  of valve and it  will stay  in  midline  because the corresponse part of tissue will fix to  the proper part of bone.

Anyway,some one might need  the  more aesthetic correction of the labia to  be  longer that can be done  after 3  or 4 monthes.

The 8^th edition

This edition we pay attention  in  thre vaginal pocket , packing  and  drainage system . Since  in our technic  the  anterio  vagina wall consists of  more graft and  posterior wall  consist  of  more flap. So  the  packing  should not  be  tight  to avoid flap necrosis and  not  too  loose to  avoid graft lost.We find  that thight packing  is not  so good  in our setting  because it conpresses the vascular  of  the  posterior flap  and cause a lot of flap necrosis then result inadequte depth of neovagina after  completely healing.  the  The concept  is  that  right after operation  the pocket  will  be very swelling  in a small cavity ,  make  the pocket  thight and result better graft survival.The drain  is change from normal Fr12 PVC radivac  drain to silicon15 mm fruited drain , so  the drain will funtion for  all 6 day  before  we take out  the drain. We found  that the good fruited drain can make  the  big change in flap  and  graft survival because  the  less correction and hematoma. Furthermore  thevaginal pocket is deeper  and  wider dissected to  the  Denonvier layer and retroperitoneal pocket that more potential space  and  give more space  than intraperitoneal space.

WE can say  that  the factor of deep pocket into retroperitoneum,adepockin ang very good drainage  is a key of depth success.