Dr. Seghers Speach
    Part_1 The First Hour

    Dr. Seghers:
    This file is a transcription of a recording made on October 3rd obtained at
    the Southern Comfort conference in Atlanta, Georgia; October 1 - 4, 1992.
    The speaker is Dr. Michel Seghers of Brussels, Belgium.
    The information here was received in November 1992 from someone who attended
    the conference, and was known to be valid at that time.
    This information is strictly for review purposes only, it does not constitute
    an endorsement, and any additional questions or clarifications should be
    discussed by consulting with Dr. Seghers or his staff.
    Only minor punctuation was added to make the text flow better for the reader.
    Only minor portions of the lecture were lost due to interruptions like tape
    change or a change in microphone position. These interruptions are estimated
    to be less than 5 minutes of a 2 hour lecture. Slides were presented along
    with the lecture and the purpose of this file is only to retain some technical
    information that might be of interest in learning something about the surgical
    This document was set using WordPerfect 5.1, courier 10 cpi font, and then
    converted to ASCII for compressing and uploading. The filename was designed
    specifically to provide for adding subsequent information or comments to be
    titled serially for reference purposes. Any additional information or
    experiences are always important and hopefully will be added, but "please
    consider" using the same basic format of 6 letters and 2 digits NAME##.TXT or
    .ARC filename with just a sequential number if possible.
    Transcribed by T.J. Stockus 11-21-92 (ending date)
    With corrections made from the original tapes and additional comments by
    Barbara Bertrand 11-26-92 (ending date) (I'm the "someone" who attended the
    conference and made the recordings.)
    **A** indicates a speaker from the audience, all other transcribed information
          was material presented by Dr. Michel Seghers.
    **S** indicates Dr. Seghers replies to audience questions during the Q & A
          followup to the lecture.
    ???? indicates a word that was not understandable.
    Double words such as "they they" or "this is this is" were transcribed as
    (?) indicates a word for which the spelling was uncertain.
    [ words ] indicate words added for clarification of what was said in the
              lecture or audience reactions.
    begin text:
    **A** Once again I come before you. You know I'm April. I'm post-op. I'm here
    today to introduce a gentleman to you that I have personally met twice in his
    own country. The first time he said no. I had the flu. The second time we were
    successful. He is without a doubt, in my mind anyway, one of the most
    humanitarian persons I have ever met in my life. He studied for his doctor of
    medicine in Belgium, where he's a native. Then he did his residency in
    Cincinnati, Ohio. So therefore he knows something about the states. He's a
    great lover of Arizona, by the way. After his residency, and he will tell you
    more about this, but he went to what used to be the Belgian Congo; it is now
    Zaire, went to Kinshasa, where he practiced medicine for a while before
    returning to Belgium. He has held numerous positions in the medicine community
    in Belgium. He is married; I forget Liz's last uh maiden name; you can tell
    them that. Anyway he has three children who are very successful in their own
    right. And so is his wife, she's pharmacist. Like I said, when I went to
    Belgium the first time, I took a little side trip and I went to Germany before
    I went on to Belgium. I caught a cold, not a cold, the flu. I was running a
    high temperature the morning he was supposed to operate. He said no. I begged
    and pleaded with him that day. He still said no. Well, I was disappointed, I
    mean after all going all that way.
    But, as I thought about it more often, I began to realize why he said no. He
    was afraid, and rightly so, that there might be complications. This should
    tell you what type of person he is. I went back later, which was this January.
    We had a little problem but we worked it out. He did the surgery, and I stand
    before you today a very happy person. I'd like to at this time, without
    further adieu, introduce one of the true humanitarians in this world, Dr.
    Michel Seghers.
    Hello to everybody. I must say that I am quite impressed by such a large
    audience and by the the quality of the of the people being here. I don't now
    if I deserve it, but anyway I am here and I have paid the reality. And to
    begin with, I have to thank, really of the depths of my heart, the organizers
    of this meeting and particularly, Mrs. Montgomery who organized this comfort
    meeting. The name of Montgomery is dear to me because as a few of you know
    know, I live 200 yards from Montgomery square. That is where you'd find my
    street, you have to cross Montgomery square. I have another Montgomery
    instinct. And when I came, somebody told me that the Southern Comfort was a
    kind of bourbon. I didn't know, but my history reminded me of my first medical
    year in central Africa as you told them, in central Africa, not Mexico, and we
    were supposed to bring a package of medical comfort which was in fact
    champagne and we used, we had to give that to the peasant people during the
    dry season. As you see already, in my introduction in fact I will make maybe
    my introduction a little long so that I keep the best part of the cake for
    later on and maybe I can be invited another opportunity. And you see I have
    been really impressed by the tremendous surgical work which can be done in the
    rough country and in the tropical area in the former Belgian Congo, now Zaire.
    Besides that I am pleased to meet here, several former patients. And I thank
    them for their presence, for their testimony and sometimes I wonder, I am
    afraid if I shouldn't wear a bullet proof jacket, this is strong. Thank you to
    Mrs. April ----, faithful patient who had to fly twice to Brussels to have a
    job done and I can confirm what I write in a major American newspaper not too
    long ago, "the ordeal is over, the change has been made, my maleness is gone
    with the flick of a blade, in fact, my blade". So, before explaining what I
    am doing now, I think I should briefly introduce myself or continue the
    introduction you have done. I am, it's important, the oldest of the family of
    eight children, born in 32, she had the delicate enough sense not to tell
    it, but so it makes it 60. And I graduate as a physician of the University of
    Pluvin(?) in Belgium in the French part of the university in 57 at age 25.
    Instead of doing a military service, I had the choice, and I chose to spend
    three years in the Belgian Congo which at that time was not yet independent.
    The first year I was a general practitioner, general physician in a cane sugar
    company, or sugar cane company I don't know exactly how it should be said.
    The two following years were devoted to two years of residency in surgery at
    the just newborn University of Leopoldville now Kinshasa in Zaire. In 1960,
    at the end of these 3 first years, I went back to Belgium, in order to
    complete my surgical training. Later on, 2 years later, in September 62, a
    new turn in my professional life since I had been accepted for a fellowship,
    not a residency, I was on* a fellowship in plastic and reconstructive surgery
    in Cincinnati Ohio, in the department of Dr. J.J. Rongek(?) and Associates,
    at the Christ and Children's Hospital, Cincinnati Ohio. That was a very busy
    and interesting time, where I was known, I'm not afraid to tell it, as the
    "brussels sprouts".
    Dr. Rongek(?) has brought my wife or two childrens. We had an addition in
    Cincinnati, since my wife had three childrens, born in three different
    continents and 1 year apart. And Eric, our youngest son, who is now pilot for
    Sabina [Sabina airlines], and still has an American passport and when he flies
    to Boston with the airbuses using this American passport he has and I don't
    You certainly must realize that I had the temptation to stay and to practice
    in the states, since I had passed the ECFMG, the medical examination for
    foreign graduates. And in fact, Dr. Rongek(?) had insisted to keep us and but
    I had just obtained an appointment as assistant professor at the University of
    Kinshasa in Zaire, the former Belgian Congo. This was the country of my first
    love, not for me professional love, but as it where I had met my wife the
    pharmacist of the university hospital who happens to be still my wife, and who
    is supposed to come tonight. I always enjoyed to work there, and you will see
    through the first slide, maybe the too long introduction, oh, it was really
    exciting. But 3 years later, in 66, due to the chronic instability of central
    Africa, and the need for my children to go at school and to complete their
    education, I decided to go back to Brussels, my home town, and to start a solo
    practice in plastic and reconstructive surgery. It was not easy at the
    beginning, since I was not very much interested in the purely cosmetic and
    aesthetic procedures. I looked for something unusual that not too many were
    doing. [LAUGHTER] Maybe you can put the first slide please. Now it's time to
    learn a few... Yes, very good...
    I've chosen a peaceful introduction with my favorite bonsai of last year. The
    red color will serve as an introduction to the following bloody slides and I
    hope that everybody will be able to stay with us this early afternoon. Now a
    few slides from Brussels that... Next please.
    You see a monument close to my office. This was built in 18 hundred and 80
    (1880) for the 50th anniversary of Belgium. Belgium was independent in 18
    hundred 30 (1830). So, it's a younger country than the United States. And
    besides both sides of the arcade a former patient [I] know had been visiting
    that day, saw war museum one side, and exhibition of old cars. It's a safe
    park to walk in, to walk in. Next please.
    A view of the Grand Place in downtown Brussels. At that time it was a carpet
    [of] flower, this happens 2 or 3 times per year. With the main building both
    sides, this is one of the 2 must in Belgium for maybe travelling people.
    The next one. The Catholic cathedral, gothic style, made in the 12th and 13th
    century. Next one.
    This is the headquarters of the Common Market, a very important building which
    is now empty because they are doing some remodelling. And the last one I think
    about Brussels. Next one.
    Yes, the Atomium, a souvenir of the World Fair in 58 in Brussels. It represents
    an atom of iron.
    Now a few slides with the old St. Joseph that some will remember, this is...
    yes St. Joseph, St. Joseph. Well known by former patients and where I started
    my practice when I came back from central Africa in 66. And I continued to
    work there until March 91, so little more than 18 months from now when it
    merged with another hospital, the new Foundation Lambert which is 3 blocks
    away and which was completely remodelled. Next one.
    A closer view of the entrance that a few will remember fondly but now it's
    this time is over; it's an old building of course. And the next one.
    On top of the street just the other side of the stop for the tram which was
    convenient to be used, a Catholic church and which we used to, to work. So
    far, yes, next slide please.
    This is my office, and as is quite common in Europe, office and home are both
    combined. This is my entrance where I live and my wife enters, yes and one
    child, the two others having moved. Next one please.
    Yes, you see. So far, so far it doesn't explain how I became involved in the
    surgical treatment of gender dysphoria. I must confess that I had absolutely
    no idea of this kind of gender problem, nor of the other problems. During my
    medical studies of sexuality and related problems were in fact "terra incognita"
    something completely unknown that nobody spoke about it. Pluvin(?) was, and is
    still supposed to be a Catholic university, but slowly things are changing.
    So, I, thinking to that, I realized that maybe I made my studies before the
    birth control pill and I had in mind, I was wrong, but, that eventually the
    homosexuality was just something for clever people who wanting to avoid
    pregnancy. I was not, this was not an easy answer, I had, and that was it. In
    fact at that time, I was not too interested in that and I kept me busy with my
    medical studies, playing bridge, playing field hockey and being active with
    the boy scouts. That was enough at that time. Next slide please.
    This is part of the history. The next one.
    This is the university hospital in Leopoldville where I started my practice of
    plastic and reconstructive surgery in 63. That view of the hospital where in
    fact my first son was born. I was so proud to go back there where I had
    received an appointment as associate professor. Five days after my departure
    from Cincinnati, I was already there in Kinshasa, Zaire 3 years after their
    independence. Quite a change. In fact I was anxious to perform a lot of
    reconstructive surgery and eventually cancer surgery. This was a tremendous
    dream and in fact, independence had been granted to Zaire in June 30 in '60,
    three years earlier, and I was convinced that all troubles were over, it was
    not. But it began differently during my second week in Zaire in October 63
    [November actually]. A Friday night listening to the Voice Of America, I
    learned that President Kennedy, had been murdered, had been shot in Dallas. I
    was still part of my heart in Cincinnati and I used to hear the voice of
    America. I set up nights because there was six hours difference in central
    Africa and here, because it happened I think around noon. I was practically
    shocked, because I think that I had seen President Kennedy 3 weeks earlier
    campaigning in downtown Cincinnati, and already at that time he was speaking
    about the problem of the jobless already in September, the end of September
    63. I quickly discovered, that not only Dallas, Texas was dangerous, but
    dramatic civil war started in Zaire. Of course, I didn't have to fight with a
    machine gun or something like that but I was in charge of many wounded. Next
    Another closer view of the university hospital, there was some rain. Next one.
    Yes, you see how everything looks so peaceful and nice, but in fact, it was
    not. Next.
    You see a view from airplane with the streaked red mud and everything looks
    very nice. Next slide.
    You see now an American plane landing with Belgian soldiers in a campaign
    airport. Next one.
    Yes, Next.
    A lot of destruction, casualties of all kinds. Next.
        And you realize not only soldiers but maybe civilians and children, like in
    Yugoslavia now, were wounded and had to be treated. But usually they were
    arriving very late several days after their accident. The United States Air
    Force was helping Belgium. They just put paint with different numbers, but in
    fact they were American planes and saying that they were not in Zaire but in
    fact they were. Next one.
    And you see a safe being blown out to take the money. Next.
    This was really a rough time, so mercenaries coming from, a few Belgians and a
    few other ones coming from South Africa. Next one:
    Of GI truck. Next one.
    This is you see, this is you see another you see marines there. In fact they
    have removed a jeep from out of the airplane and putting on behind the truck
    and to bring some supplies. Next one.
    Yes that's ok(?). Next.
    But you see, we were brought many soldiers wounded and usually it took 2 or 3
    days before reaching the university hospital.
    ********VOLUME LOST FOR TWO MINUTES********
    2 or 3 SLIDES:
    Running commentary on how Seghers fixed up a wound ripping off a part of a
    black soldiers upper lip and most of the skin of the lower lip and jaw. Really
    as messy as SRS.
    ********VOLUME LOST FOR TWO MINUTES********
    The last slide of my African practice will be interesting because the next one
    you will see... You will see this is a long man being a chief and he had been
    sent to specialized hospital since he was suffering from leprosy. And after he
    was cured of his leprosy, he was referred to me because he had breasts that he
    didn't want to have. I just knew that it was connected with the testicular
    atrophy, but the true reason was not investigated and is still unknown. So I
    just decided to remove the breast, do subcutaneous mastectomy, so you see I'm
    doing sometimes things for female to male. But he was a male. Next one.
    After the mastectomy, subcutaneous mastectomy, through peri-areolar incisions.
    This is you see is not any more afraid to show his face. So now at the end of
    66 when I was looking for an interesting field of practice, since I didn't
    have the kind of patience to talk with patients for cosmetic procedures,
    despite it could lead to a very easy and rich life. In fact I wanted to
    perform reconstructive surgery, I didn't find it because, since I am doing
    now, as you know, constructive surgery. Next slide please.
    This is one of the favorite sentence of Dr. Rongek(?) with whom I trained in
    plastic surgery. He used to say that "In order to succeed in life you have to
    find a need and then to fill it". This can be available for everybody in all
    different fields, just not like that. But I remember that he like to say that
    to everybody and to give lessons sometimes. Sadly enough, Dr. Rongek(?) has
    passed away 10 years ago. I did not visit him soon enough, and I will always
    remember his kindness and welcome and I was always amazed how he was proud of
    his work, of his city Cincinnati, and how he was proud of the United States.
    He gave me a great lesson that I will keep for always, and in fact in being
    here today, and regularly taking care of American patients in Belgium, I have
    the feeling to pay him back some kind of a debt. Instead of doing
    reconstructive surgery, I found some constructive surgery in the field you are
    interested in. In 1967 my attention was drawn to the case of a Belgian surgeon
    being sued by the justice department because he had done what was called an
    "unnecessary mutilation" of a young patient who had died suddenly after
    surgery. This young adult was, in fact, one of the first male to female sex
    reassignment surgeries done in Belgium. There was no complaint by the family
    but an anonymous letter came out from the hospital to the justice department
    who wanted to investigate the question. That's the first real notice I have
    about the problem back in 67, 68. In reality this patient had died from a huge
    pulmonary embolism which can occur and which I almost had with one Belgian
    patient. This is a consequence of excessive use of female hormones and that's
    why I and we always want patients to stop taking female hormones at least 2
    weeks before surgery and some very cautious surgeons require 6 weeks, but I
    think not too good idea. The case of that surgeon was finally dropped. The
    surgeon had no more problems except that all potential surgeons became very
    cautious and reluctant to start that type of surgery. Sometime later a French
    psychiatrist introduced me the case of one of his patients. This young man,
    who looked like a female and was badly needing sexual conversion. Several
    attempts of suicide had already been done in despair. I studied the case, it
    took some times. I studied the literature and I slowly realized that I had
    become the only hope for this patient. The psychiatrist insisted that I had to
    do something otherwise it could finish in full catastrophe. After studying the
    literature, without having seen any operations performed elsewhere I felt
    ready. And you see my applicant background helped me to jump, and to try which
    in fact is not delicate and not so difficult. And my first case was done in
    St. Joseph's in the early 70's. I was lucky not to have complications and the
    result was pretty good. I still meet this patient, it means that she is still
    living.[Laughter & applause] This became known and I have made a communication
    at the Belgian Society for Plastic Surgery of which at that time, I was
    accredited. In fact, at that time, at that period, the situation was pretty
    bad in the Belgium with many accidents and a few vagina-rectal fistulae had
    been done by a surgeon, always the same one, who was dreaming to build, I
    think, queen size vagina, 7 inches by 2. That's the best way, that's the best
    way to look for troubles and there were always big troubles, big complications
    and a lot of trouble. At that time, such already, fortunately, such surgery
    could be billed to Social Security, and even when Social Security is taking
    care, it is very easy, even if you have complications, because they take care
    of the complications too. So, it's another way to help when I decide such a
    price for one week for American patients. It's for the complications not for
    my pocket. Yes it happens.
    So, and at that time the situation as I told you just before was as bad, that
    two of my first cases had asked just for the penectomy and orchiectomy without
    any vagina being made. They were so afraid of the complications they wanted to
    survive and this went of course very easily. They were happy, but I must say
    that later they had regrets their decision because penile skin had been
    discarded. Later 1 of these 2 patients had later a secondary vaginoplasty with
    an intestinal flap done in the Netherlands. I am aware and I have been in
    touch with a few patients who claimed that they were asexual, asexual or
    neutral. And I think in a few weeks I will see a patient coming from the west
    coast who just wants penectomy-orchiectomy because he or she says, she
    declared as an asexual. This happens and this in my opinion can be connected
    to the story of Dr. Couchmerre(?), a French physician who hated to be a man but
    didn't want to be a woman. In fact, there is not too much choice possible but
    anyway, they want, it seems, that they are too maybe can be discussed later, a
    few people, unique people, want to have no sex at all. Why not, maybe less fun,
    but what an economy of problems and certainly life would be easier. No slowly
    we ?????. Next slide please.
    This will list my requirements, they are classical and well known by most of
    the eventual... Classical is by the eventual candidates for surgery.
    A psychiatrist's report. I am a little uncertain of what level because I know
    in the states you have M.D.'s, you have Ph.D.'s and psychologists. In Belgium,
    we need to have a report made by an M.D. I think the Ph.D. in Psychology is
    the same as an M.D. but I am a little confused in that. I'm safer being in
    Belgium for that. Next slide please.
    The next requirement is the endocrinology report sometimes it's done by a
    general practitioner who knows the patient. I want to meet or to have records
    of somebody knowing the patient since a certain amount of time and telling
    that he's reliable and he's not taking female hormones in the spring or in the
    fall and from time to time changing his mind.
    A social history written by the patient himself. Sometimes it's included a
    psychologist's report, but quite often not.
    I need two pictures, now I require because I had a surprise with a very heavy
    patient. One with a passport size picture, and another one with full body height
    to see if she pass well as a female and to see if because I had a surprise of
    the patient being admitting 270 pounds and in fact she had sent me pictures
    with children in front and the children were healthy and I didn't realize that
    she was not heavy but, very heavy. Next one.
    I require the AIDS test should be non-reactive. It should be done at the
    maximum, 3 months before surgery and anyway it's checked in Brussels, but it's
    to avoid complications or discussion. I discovered in August I had an AIDS
    test I had received, the document maybe wrong and the AIDS test was positive
    in Brussels and finally the operation had not been performed. In fact I found
    it easy because not only the AIDS test was positive but this patient was
    really an advanced case. She was already very sick with few white cells. And
    so this I postponed and that I decided not to do.
    Maximum weight 200 pounds. In heavy patients, usually heavy patients that have
    a very short penis, sometime you have difficulties with fat to find it. I said
    200 pounds, but I have delicacy not to weigh people being a little over. So, I
    have them before, and my scale's in kilograms, so it's more difficult for me
    to judge in pounds. So 205 that would be right, I think, but if I write 220,
    I'm sure 230 or 235 will come. So I had to put a limit.
    Minimum age 21 years of age. I had done a few Belgian or French below that
    age, but with the written agreement of the parents and it happened once with
    an American girl, but her mother was with her, she was below below 21.
    And I need also a report of the general health. This brings me many surprise
    because you see, when people are afraid to be refused for such reason or
    another one they have a tendency to conceal a problem which sometimes appears.
    That is why I have, you see, grey hair and even I ask a E.K.G., a cardiac
    check above age 35. Because I also had a cardiac, some problems with cardiac
    complications during surgery and a little after surgery, but so far nobody has
    died. So far, but I think it could happen, it almost happened because I had a
    patient from Belgium and she was not covered by the Social Security and I had
    asked her for a last time to check in my office 4 or 5 days before her
    surgery. And she came and she said, "Yes doctor, my physician has tell me to
    tell you that I have some phlebitis in my leg. And I touched that this was
    hard, this was venous obstruction with clots and some kind of infection. There
    is a big risk of embolism and I evidently told the girl that I would do the
    operation but that it would be postponed. Then she started crying "Oh if I
    knew I wouldn't have tell you. I said "Yes, then if you didn't tell me then I
    wouldn't see it and I would do the operation, but you told me so, it's
    postponed". And fortunately because 2 weeks later her physician called me that
    she had made a massive pulmonary embolism and that she had to stay for 2 weeks
    in the emergency room, and so far she's not yet, she didn't have her surgery
    because she's in very poor condition and all the money that she had saved for
    reassignment, eventual reassignment, had been used for [her recovery from]
    pulminary complications. So, we have to be careful if there's no Social
    Security taking care. Next one.
    You see in patients like this, being usually overweight even you don't see
    the difference between male or female and surgery would be very difficult and
    it's preferable that I have see... Front view. Next slide.
    You see the gas and the operating table the beds we use are not ready for that
    type of patient. Next slide.
    You see I have a lot of paperwork and from time to time from I had somebody
    told me that she didn't get an answer to two letters. Another one, the letter
    came back but the address was incorrect so it's normal but fortunately it went
    back. This takes me a lot of time and I write or I dictate certainly 15
    letters per week, related to this kind of activity. Now we will start in the
    real question. Next slide, please.
    You see, once patient has been accepted, this is the beginning of the
    procedure the patient be lying on the operating table in gynecologic position
    with just a front, with head a little lower. You see the perineum and the base
    of the scrotum. Next slide.
    I think this is what I do now, with a long skin flap, perineal flap this
    posteriorly and which will be used to line the posterior wall of the vagina,
    and this is has a double effect. It's increased the width of the entrance of
    the vagina, it increased the size of the vagina and it makes the penile skin
    to go deeper, so it increases the depth too. This I'm doing routinely since
    almost 2 years now. And earlier I was doing just a split in the middle of the
    perineum where there is a kind of scar which is congenital. This is the 2
    anterior parts fusing together and that's why in my opinion this flap survives
    because they are [not] against the rules of plastic surgery. You see 1 of the
    rules of flaps is that the length should not exceed 3 times the width,
    otherwise because there is no blood supply, and quite often during surgery
    during surgery when it is hanging down you see that the end is becoming blue.
    But I had those flaps very long until going into the base of the penis and
    this is using to line not only the posterior wall of the vagina, but sometimes
    for those having a short penis and they are in fact, they are not uncommon.
    This kind of patient has rather a short penis or they are circumcised or even
    if they have a big fatty layer, it's difficult and some kind of skin should be
    added. Before I was using split thickness skin graft taken from the dermatode
    from one side or the other side of the buttocks or I was using full thickness
    skin graft taken from scarred scrotal skin. At the beginning I was just doing
    a midline incision going too deep, after that I made a reverse T, then I made
    a small triangle, and now I make this longer and longer. This flaps has been
    certainly helpfull. Next slide please.
    I think, yes. That's another type of a flap to show that here the flap is not
    going as long as I think the maximum could go. But this is a split, this is
    divided in the midline to separate and just this end of this flap is attached
    here to bring blood supply from behind will be attached between the 2 end of
    the penile skin in which will be divided. You know you see in this slide that
    there is a kind of line, a kind of scar, this is a congenital scar, and in my
    opinion, blood supply is not crossing the scar. So it means that there are 2
    different blood supplies and I think that's why these flaps are surviving
    against the rules, the general rules of plastic surgery because we have
    doubled vascularization. But sometimes it can be some part can die. Next slide
    You see, this is a lucky patient and in fact she didn't know that she was
    lucky. No problem with this type of a penis, but which is quite uncommon, but
    just except maybe among black patients. In a case like this who is not
    circumcised, this came from inside the prepuceus skin. It could be discarded
    because it certainly [is] a huge amount of skin and sometimes but this is
    rather uncommon, quite often you see the reverse situation. The next.
    You see this is another maybe amusing picture. This is a kind of skin disease
    with discoloration, it's not very bad the white spots related sometimes in the
    face to be related to the sun exposure. So you see the shaft of the penis not
    so long, and it's circumcised. With it's circumcised, certainly you lose at
    least 1 inch, 1 inch and half of skin which reduces the length of tissue which
    can be used. On this slide I want you to notice the anus of course, the
    entrance of the vagina will be here [he points above]. And you have to realize
    that the penile skin, of the penis is attached in front of the pubis if we use
    the penile skin to make the vagina, you have to bring this skin down and you
    lose part of it and some cases and especially in very heavy patients, there's
    no penile skin left when you arrive at the site of the vagina. And some
    patients, many say [that] when erect they are 5 or 6 inches, sometimes they
    claim more. I wish for things from time to time. So you lose almost 2 inches.
    It is possible to rob the abdominal tissue to gain a little, but at the
    maximum 1 inch. When I attach the tissue, the abdominal tissue down which is
    not always possible because some, quite a few patients they had already
    abdominal surgery before, like hernia repair or some abdominal surgery and the
    abdominal skin, abdominal tissue is attached to the depth because of previous
    scars. And that condition is difficult to bring everything down. Sometimes
    some patients have surprise or they are amazed to see in their lower abdominal
    in the midline, a dimple, and when it hurts when they push it's because there's
    a stitch attaching the tissue lower to bring the penile skin in the direction
    of the perineum and that stitch is supposed to break after 1 or 2 weeks,
    sometimes longer. Next slide please.
    You see the operation has started. Maybe I should put more slides in between
    but you see that here that the urethra has been separated from this is the
    bulbo uh corpus cavernosum, making the shaft of the penis. The urethra has
    been separated and seceted(?) down but we put a catheter inside with a self
    retaining tube #20 usually which will stay in place for 8 to 9 days. But this
    is not a complete urethra because the end, the terminal turn or arm of the
    urethra is still attached here beneath the skin beneath the tip of the penis
    which is not yet liberated. And as you see here the base of both corpus
    cavernosum that will be cut here in "V "and the base of this 2 erectile tissue
    will be cut to make some kind of look alike or feel alike clitoris. Just
    beneath, here beneath this is the pubis bone. Next slide please.
    Yes, I have regularly visitors. Some they ask if they could come to the
    hospital. Some like it, some cannot stand it. This one, she was very sorry to
    see the penectomy and orchiectomy. She was very sorry for that but fortunately
    she found husband a few months after.[Laughter] Next slide please.
    Now a center view when the operation has progressed you see the perineal flap
    which has a grey and little bluish color hanging down. You have to be careful
    when you dissect because you have to keep it thick and not to go too deep too
    deep at that place where it will turn because alive blood and blood return too
    is passing through. This end has to be preserved otherwise it will die and put
    more problems. You see now that the urethra has been brought upward and there
    is a forceps or mosquito attached to this triangular piece which is the corpus
    spongiosum around the urethra. This is the turn, a delicate place between the
    horizontal male urethra and the vertical male urethra going in the direction
    of the prostate and the bladder. This is a right angle turn and I must say I
    am aware that those who have some kind of problem in the direction of their
    urination it's coming depending on the level where it's cut. There is right
    angle turn and it's surrounded by corpus spongiosum which is the second
    erectile male tissue which doesn't help the surgery and later on some patients
    keep complaints there because it's too swollen or they have pain or swelling
    when they are excited or it's bulging in the vagina making dilation or
    intercourse difficult or the penetration difficult. On top of that you see
    that the other tissue, I don't think that the clitoris has been made because
    the penile shaft is still upward. Next slide please.
    You will see now the difficult part of the procedure, it's because you see the
    perianal flap is pulled backward and in front it's pulled upward and this is
    where it happens, the difficult part of the procedure. I used to say that the
    removal of the testicles, that's very easy. 100% guaranteed to be quickly
    done. That's how long it takes for me to do it, it happens. The penectomy,
    removal of the penis is more delicate because this is erectile tissue you can
    get bleeding. Bleeding is great risk in that kind of surgery and it's another
    delicate point, it's the new junction, the making of what you call, some call
    it the pee hole or the urethra opening. The attachment of the shortened
    urethra, through the skin or through a hole in the skin is quite often, still
    too often the site of narrowing and infection. But so we have now, I don't
    have good slides I think in focus. Seen in the back, this is the part of the
    procedure I use to prepare the surgical site including some strong stitches on
    both sides where I go to catch the blood supply to this area and this reduces
    the bleeding. It makes the surgery easier, faster and less complicated because
    that's the place where you run, you can run in trouble because after 1 inch, 1
    inch and a half, we face a kind of fibrotic sheath over toward the upper
    neurosis denouvilier(?) (French anatomy) which closes the male pelvis from
    the prostate to the rectum. And we have to go through that. Just that, not too
    much in front you go to the prostate, not too far behind in the midline it's
    dangerous to try to go through. But you have with blunt dissectors, with
    scissors on 1 side or on the other you try. With experience, it's going now
    very fast in most cases this is a very tricky a very difficult place because I
    have to tell you, you know that when we build a place for the vagina we made a
    split originating from this split but we don't move any tissue. We don't
    remove a caraffe of tissue and replacing it with skin and mold of sponge
    either from those that I use to put or mold in the vagina. So, you make a
    split, you divide, you separate and you squeeze something inside and it has to
    stay inside. It's amazing to me that it's going so well or not going well
    in any case. So, next slide please.
    Now this section has been complete. You don't see it well but you have have to
    believe me. I put some sponge to do some kind of compression because of it
    will be removed when the penile shaft, when the mold made of skin will be put
    inside. Here you can see a little of the dimple because because the abdominal
    tissues have been brought down and attached to the pubis, sometimes it's
    attached to the clitoris, but that's transitory, but it dissolves in 1 or 2
    weeks. You see the penile skin here and the end where it was separated from
    the glans because the glans is discarded. I tried to save one to save one part
    of it someone said yes we can use the glans it makes like if you have a cervix
    in the depth of the vagina and that's dreaming a little much I think. But so
    the ends of the penile skin is closed with interrupted sutures since it was
    split in the midline in between we start, you see a little blood running, I
    try to go fast. When I was in training, when I was performing surgery in the
    states, I was always amazed that they spent a lot of time to stop all bleeding
    to coagulate, this is this is for those because it takes a lot of time and
    they use a cauter[izer]. They burn it with the electricity but the more you
    burn the more dead tissue you do. And this is jeopardizing the bleeding for
    later on [usage]. In my opinion, maybe because I worked in Africa, as
    long as it doesn't bleed too much I go through and I advance and shorten and
    stop it when everything is finished and not postponing. So if you take an hour
    longer to make the procedure, it means you find a maybe more blood loss, more
    medication to stay asleep, and all this, this is a choice you have to study and
    to judge to evaluate in each case. So you see, this will be attached, this is
    difficult, because you see that the urethra is staying there, I cannot put it
    on the table. I have, at this place I have to put it 1 side or the other and
    this is the reason why, this will amaze you but I had difficulty to put
    later on the new pee hole exactly in the mid-line. Because that skin is very
    stretchable and you can't do, I'm amazed myself but I cannot do, I try, when I
    do it I try, I try to have it in the middle, I paint it in the middle but
    sometimes it isn't. Next slide please.
    Yes you see, the attachable rear part but it's turned the other way. You see
    the end of the penile skin, it looks like the blood catheter is going out,
    this is so, but it's behind. This is has to be, it's out of the way dropped
    out earlier it was hanging here, now it's hanging the other way. It's stopped
    going in so the penile skin which is still turned reverse it should be, it
    will not go in that way, it will like so, it will be turned the other way to
    have the skin going to the outside, and to have this part against where it
    will be attached and where it's supposed to be. You see this is interrupted
    still with suture to the end, it's almost complete at the other way. So
    usually I start always that way finishing, finishing on this side not to think
    the ???? maybe because I'm right handed otherwise a left handed would be the
    other side. So it doesn't make any difference. Next slide.
    You see, it has been turned completely and the skin is inside now. which is
    the inside of the future vagina, but it's not yet in place. You have to
    believe me that ????? that section has been closed, the separation, the split,
    there are a few sponges doing some compression waiting for that will be ready.
    You see that the posterior flap is going up, it's a little twisted there and
    going into here. The penile skin is going a little longer. So now the next
    step would be to fill that with ????. I think... Next slide please.
    You see I started to fill it with some pressure, not to put too much because
    if you put too much, it's again the question of experience, of feeling, you
    have a certain amount of tissue. If you put too much or too large here, you
    have less length. You have to chose what you decide. I know that the dream is
    better to have it long enough, even if it's narrow. So you, this white stuff
    it's some vasiline, some kind of vaseline an anesthetic glue to pass it's half
    filled but it has to be many things and not are easy to say, and some are not
    always easy to do, and it takes experience. That's why I think it's still
    changing. Next slide.
    Here you see the iodoform gauze going in. It's the same ????. There it's
    completely secured. And this has to be completed after... it will be pushed
    in. It's difficult to render that in slides... maybe in the movies or video...
    Ok, next.
    That's another continuation of the first 1. You see another case being almost
    ready, but it's interesting because you see the posterior flap starting here
    in front of the anus, going to make this, the post of which will line the
    posterior wall of the vagina, but this patient has a very short penis. You see
    the entrance of the vagina will be here. There's just maximum 1 inch skin to
    go inside so there is no tissue to be used, almost no tissue to be used to go
    inside. In this case that was a very long flap, turning here and this part is
    a continuation of the perineal flap, this will line the anterior wall of the
    vagina beneath the bladder, beneath the prostate in the back. And when I see
    that, when I do that I pray that it will survive. Because I'm not always
    convinced that it looks well. The flap, a tip of the flap, when it's failed,
    why, that's no problem maybe it's less arterior blood coming, what's dangerous
    to have blue flaps. When it's blue it means the blood venous return being
    impaired and that's the way problems. Next slide.
    This is another case where you see the urethra brought on the left this time.
    You see the vagina will be just behind the skin beneath since this is the
    urethra the junction of the horizontal and vertical part so the vagina will be
    here. You see that the penile tissue remains of a few years ago, and the
    penile skin must really be short. Again, there's no tissue left when you
    arrive at the vagina entrance. And so, in this case, I don't do that too often
    because I'm not convinced that it stays, that it survives... I try to at least
    I'm intent. This is a split thickness skin graft reversed of course, which
    makes already some packing inside and that will be squeezed and pushed inside,
    this will make a vagina with some split thickness skin graft, taken from.
    That's why we take this type of tissue because because the graft has been
    taken from behind the thigh this time. But I don't like that too much because
    the junction of the penile skin which is some thickness, some ductos, I don't
    know in english... It's not very thick but thick at the junction of these two
    different tissues there is always a kind of shrinkage and stenosis and a site
    for pain. There is some vagina, but it's impossible to go there. Next slide.
    You see this is the procedure when it's progressing. You see a open urethra in
    the middle it has been fastened to a hole and I removed has some skin in the
    middle. You see that this is the perineal flap is going inside. This is some,
    this is the iodoform gauze which is held in place and pushed within by the
    This is, this is the place that will be the new urethra opening, this is not
    yet complete. So the anus, the vagina, the place where she urinates will be
    here, you see already that 1 side of the labia majora has been done. There is
    some removal of the scrotal skin. It's attached something like that. You see
    again it's too wide apart already but we cannot go in the midline because the
    blood supply is running there. And there is one silicone tube for drainage,
    you know that in case of bleeding to have it outside better than inside. The
    left labia majora is not yet finished. There is some excess of tissue to be
    removed, but it's already marked with methylene blue for the inside. And the
    outside there is some skin discarded although sometime I was regularly using
    as a full thickness skin graft. But you see that there is no place for some
    kind of labia minora, for the small lips which should be a little inside. With
    lucky patients with a very big penis there is some extra skin you get some
    extruding, some of the vagina is coming out and later on eventually it can be
    changed or adapted to look like labia minora. It has just been finished with
    the second tube. The next slide.
    Yes, you progress again, same ???? as behind. Behind this is the entrance of
    the vagina with the packing inside. You see that the second lip is closed also
    with a silicone tube, and in the midline you see passing through a hole, it's
    not real hole. There is a removal of some skin and through which I pass the
    urethra, but the urethra is still with the corpus spongiosum around it. There
    is a stitch there behind, so that it does not bleed, but it will have to be
    removed. You see here that there is another stitch strangulating the base
    and limiting the escape of blood. This is again, something technically
    difficult. Next slide.
    And during many months I have problems of bleeding at the base and I didn't
    know how to attach or to have a successful attachment of the shortened urethra
    with the skin. And I am very grateful to Dr. Biber, that I had met at the
    meeting of the Harry Benjamin Association and I tell, I told him that I had
    problems there and he said "YES, IT IS QUITE EASY, YOU CAN USUAL DO AND SO AND
    SO, and he explained me very kindly. I don't know if he regretted that day for
    long but anyway I was still very grateful for that. You see at the beginning,
    the urethra was longer, coming up to here. It has been depressed to get you,
    rope has been removed and it has been split until the other ligation. It is
    strangulated there is almost no bleeding and you see that it has been split
    and you see the "Y"

Return to Surgical Page Return to Top of Page
Return to Main Menu