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The phenomenon first came to the attention of modern medicine around the turn of the twentieth century, where it was described as a psychiatric illness by Richard von Krafft-Ebing and other early sexologists.
With the primordial classification of the condition as a form of delusional disorder, all means of psychotherapy were attempted to convince patients to abandon the belief they were trapped in the wrong sex body and to accept their assigned gender.
Such attempts were widely and consistently ineffective to convert the adult transgender/non-binary (TGNB) patient or to relieve their suffering, which was regularly severe enough to drive patients to genital amputation or suicide.
Therapeutic benefit was first achieved using the affirmative treatment pathway, originally pioneered in Magnus Hirschfeld's Institute of Sexual Research in 1919 in Berlin, until it was sacked and its library burned by the Nazi party in 1933.
His affirmative treatment pathway supported patients’ case-by-case need for social transition, need for the newly available cross-sex hormones, and even the need to refer patients for gender-affirmation surgery where appropriate.
The Danish-American trans woman Christine Jorgensen, who had become famous for undergoing a gender-affirming surgery in 1952, used her growing influence to create “as much good publicity as possible for the sake of all those to whom I am a representation of themselves.”
The EEF supported Benjamin's mission to link transgender patients to capable providers, and it directly funded almost every aspect of research and applied science related to transgender care in the 1960s and 1970s.
The opening of the Johns Hopkins Gender Identity Clinic (GIC) in 1966 was closely followed by the establishment of GICs in the United States at The University of Minnesota, The University of Washington Seattle, Stanford, University of California Los Angeles, University of Texas Galveston and Northwestern.
The positive public image of trans woman Christine Jorgensen, Harry Benjamin's growing provider network, coupled with the arrival of the first high-volume provider since Burou, together marked the beginning of the renaissance in transgender surgical care.
They held the archaic position that TGNB patients suffered from a form of delusional disorder and that all aspects of the affirmative treatment pathway, most notably surgery, were inappropriate in the treatment of a purely psychiatric illness.
Expert transgender healthcare providers, who saw patients benefit from gender-affirmative social transition, hormones and surgery debated the opposition camp, asking the critical question: “what meaningful alternative help have you been able to offer the transsexual patient?”
In this new era of gender-affirming surgery, where a growing number of urologic, plastic, gynecologic and general surgeons are becoming specialty trained in gender-affirmation surgery, the fascinating history of GAV is more important than ever.
Random Skin Flaps and Pedicled Fasciocutaneous Flaps
Descriptions of surgical interventions to restore form and function for vaginal obstruction or non-functioning vagina, be it from imperforate hymen, vaginal septum, vaginal hypoplasia or vaginal agenesis, date back to Greek antiquity.
Incision of the obstruction or sharp dissection for creation of a canal in the pre-aseptic era generally resulted in injury to the urethra, bladder or rectum with fistula or entry into the peritoneal cavity and death from infection.
Even with improved safety in canal dissection due to increased surgical prowess and adoption of aseptic technique, simple perineal rectovesical canal dissection for creation of a neovagina proved insufficient.
Therefore, indwelling neovaginal molds with progressive dilation and epithelialization over a period of months following dissection were attempted in cis-women, but these too with dissatisfying results; stenosis, incomplete epithelialization and excessive granulation tissue.
Ponten popularized the pedicled fasciocutaneous flap (PFCF) in 1981, a culmination of decades of combined experience in the plastic surgery community that described principles for creation of well vascularized skin flaps.
In 1956 the Danish surgeon Poul Fogh-Andersen reported a case of one foreigner who had come to Denmark seeking gender-affirmation surgery and when denied, he attempted to castrate himself; forcing the surgeons to complete the orchiectomy.
Sir Harold Delf Gillies and David Ralph Millard devised and performed the first anteriorly pedicled fasciocutaneous tabularized penile inversion flap to line a neovagina in 1952 on trans woman Roberta Cowell.
Milton T. Edgerton described the modified Hopkins method in 1970 in which posteriorly based pedicled tabularized PIV was performed with preservation of the scrotum which was utilized in a delayed, second stage operation for labiovulvoplasty.
Use of full thickness scrotal skin graft anastomosed to the open end of pedicled inverted penile fasciocutaneous flap to augment the proximal canal and apex became commonplace to create neovaginas of adequate dimension, generally defined as 12.5 cm in depth, 3.5 cm diameter.
W.F. Sneguireff performed the first primitive bowel substitution vaginoplasty (BSV) in 1892 in cis women using pedicled terminal rectum and anus, pulling down the proximal rectum to perform anorectoplasty.
In the combined abdominoperineal procedure, an isolated ileal or colonic flap is obtained, primary bowel anastomosis is performed, and the pedicled bowel flap is pulled through for enterocutaneous anastomosis.
In search of a GAV method with utility in cases of limited genital skin or in cases of revision vaginoplasty, the Stanford Plastic Surgeon Dr. Donald R. Laub expanded and modernized the bowel substitution GAV.
His findings were corroborated by a 2014 Dutch Retrospective review of 686 patients who underwent rectosigmoid vaginoplasty and 169 patients who underwent ileal vaginoplasty from 1996 to 2013 for any indication; including cis-female patients with primary vaginal agenesis from any cause, cis-females with acquired conditions like trauma or gynecologic malignancy, and vaginoplasty for gender-affirmation.
Disadvantages of BSV include intestinal surgery with potential accompanying donor site morbidity such as ileus, increased length of postoperative hospitalization, introital stenosis, and bothersome neovaginal secretions.
Though BSV has been demonstrated as a primary GAV method and there are some that advocate for its use as a primary method which should be offered to all patients, the strongest justification for BSV is refractory neovaginal stenosis.
Friedrich Schauta credited the Russian Gynecologist Dmitry Oskarovich Ott with discovery of the technique though S.N. Davydov became the namesake of the modern procedure after his case series in 1969 in cis women.
Although creation of a deep and wide neovaginal canal is easily performed by expert surgeons using standard penile inversion techniques, the authors suggest that an additional improvement of the peritoneal vaginoplasty technique is the ability to dissect the space robotically.
Because the peritoneum of the rectovesical pouch is used to form the vaginal apex, this technique may result in increased depth compared to standard PIV in which the dissection stops at the peritoneal reflection.
Donor site morbidity in Zhao and Bluebond-Langner's cohort was rare with no instances of peritonitis and only one case of small bowel herniation through a separation in the peritoneal flap which was treated with subsequent laparoscopic surgery.
The prolific Amsterdam group is often cited as influential in their formal announcement in the academic literature that aesthetic and function, patient focused outcomes, should be considered of principal focus as well.
By the mid-1990s, following 2 decades of collaborative experience in the GAV surgical community, there were well described principles for creation of a more aesthetic and functional clitoris, urethral meatus, vaginal introitus, anterior and posterior commissure, and labia majora.
During penectomy, the glans penis was transected free from the more proximal corpus spongiosum and left attached to the penile skin tube there at the apex and, once inverted, it formed a sensate neocervix.
In 1968, Barinka et al first described a successful method for functional preservation of the clitoris in intersex patients, which would prove important in the creation of a properly sized, sensate, orthotopically located clitoris during vaginoplasty.
It should be noted that due to many documented instances of profoundly dangerous and negligent care, John Brown ultimately had his medical license revoked and was imprisoned for second-degree murder of a patient.
Alternative methods of functional or cosmetic clitoroplasty were attempted but all with inferior outcomes compared to DNVPG; these included free composite graft of glans, pedicled corpus spongiosum or urethral substitution flap, corporoplasty, ventrally based glans flap with intact corpus spongiosum pedicle, and even a purely aesthetic subcutaneously placed chin implant.
Extended excision or corporocleisis of the residual proximal corporal bodies, and spongiocleisis of the residual bulbar corpus spongiosum was adopted to prevent unsightly, painful, potentially obstructive engorgement of this erectile tissue.
An innovative posterior triangular flap was described by the Amsterdam group to break the circular introitus and create a more natural and functional posterior commissure without dorsal introital webbing.
Utilizing rigorous re-review of the primary literature, historical research and historical discovery we present an update to the traditional historical narrative which had left behind several significant events and persons.