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.
**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.
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
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
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.
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:
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.
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********
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...
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"