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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 28  |  Issue : 2  |  Page : 123-126

Interposition of a unilateral singapore posteriorly based fasciocutaneous axial flap for treating rectoneovaginal fistula in a male-to-female trans-sexual patient


Inspira Health, Mullica Hill/Vineland, New Jersey; Icahn School of Medicine at Mount Sinai, New York, USA

Date of Submission25-May-2019
Date of Acceptance20-Jul-2019
Date of Web Publication18-Mar-2020

Correspondence Address:
Dr. Woojin Chong
Urogynecology at Inspira Health, 2950 College Drive Suite 2A, Vineland, New Jersey, 08360
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_44_19

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  Abstract 


Rectoneovaginal fistula (RnVF) is one of the major complications for the gender reassignment surgery. Closure of the RnVF with interposition of a pedicled tissue flap is a useful surgical approach to reconstruct the perineal space and provide neovascularization. Martius flap, gracilis muscle flap, and Singapore flap are the options of pedicled tissue flap. An HIV-positive 37-year-old male-to-female trans-sexual patient presented with a large RnVF (8–9 cm × 4 cm) after penile inversion vaginoplasty. A modified Singapore flap was performed to repair RnVF and to reconstruct the perineal space. Vaginal reconstruction with a fasciocutaneous Singapore flap can be considered for male-to-female trans-sexual patients with a complex RnVF as it provides excellent neovascularization with a sensate flap and desirable cosmetic outcome.

Keywords: Fasciocutaneous flap, rectoneovaginal fistula, Singapore flap, transgender


How to cite this article:
Chong W. Interposition of a unilateral singapore posteriorly based fasciocutaneous axial flap for treating rectoneovaginal fistula in a male-to-female trans-sexual patient. Turk J Plast Surg 2020;28:123-6

How to cite this URL:
Chong W. Interposition of a unilateral singapore posteriorly based fasciocutaneous axial flap for treating rectoneovaginal fistula in a male-to-female trans-sexual patient. Turk J Plast Surg [serial online] 2020 [cited 2020 May 27];28:123-6. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/2/123/280989




  Introduction Top


According to the American Society of Plastic Surgeons, a total of 3256 “transmasculine/transfeminine” surgeries were performed in 2016, with a 19% increase over the prior year. Complications after a male-to-female gender reassignment surgery include deep and superficial infection, rectoneovaginal fistula (RnVF), pulmonary embolism, and bleeding.[1] RnVF is one of the major complications after the gender reassignment surgery (incidence ~ 1%).[2]

Surgical management for rectovaginal fistula in natal women depends on the localization, size, and etiology of the fistula: (1) sewing an anal fistula plug or patch of biologic tissue into the fistula, (2) using a tissue graft, (3) repairing the anal sphincter muscles, and (4) performing a colostomy before repairing a fistula in complex or recurrent cases.[3] Closure of the fistula with interposition of a pedicled tissue flap is a useful surgical approach to reconstruct the perineal space and provide neovascularization. Martius flap, muscle flap, and Singapore flap are the options of pedicled tissue flap.[3] Singapore flap is a pedicled pudendal fasciocutaneous flap from the thigh centered on the labial crural fold with a base at the perineal body.[4],[5],[6] This flap is sensate as the cutaneous innervation is preserved.

Compared to rectovaginal fistula repair in native women, the surgical repair of RnVF is more difficult and unpredictable because of the presence of a skin flap, a deepness of the rectal lesion and uncertainty about which route is the best for approaching the lesion.[7] The present case report displays the management of a male-to-female trans-sexual patient with RnVF with interposition of a unilateral Singapore posteriorly based fasciocutaneous axial flap.


  Case Report Top


A 37-year-old, HIV-positive, male-to-female trans-sexual patient presented with stool leakage from the vagina 1 week after penile inversion vaginoplasty performed at another facility. The original operative reports were not available for review. On examination, the vaginal introitus was wide open leading directly into the rectum. the anterior rectum wall was absent for a length of 8 cm from the anal verge. Colorectal surgeon was consulted. Digital rectal examination revealed a palpable defect just above the anal sphincter and right side of the anterior midline. The anal sphincter tone was intact, and the anorectal mucosa appeared normal. The office sigmoidoscopy confirmed physical examination findings. Multidisciplinary surgical planning was made. After informed consent was obtained, a modified Singapore flap was chosen for the patient to repair RnVF and to reconstruct the perineal space. Singapore flap provides neovascularization; therefore, cutaneous innervation can be preserved. The patient also desired for the least disturbance on her augmented thighs.

The procedures involved with laparoscopic temporary loop ileostomy creation/repair of rectal mucosa transvaginally/repair of RnVF with interposition of Singapore posteriorly based fasciocutaneous axial flap/revision vaginoplasty with correction of stricture. First, a temporary laparoscopic loop ileostomy was created with an ostomy bag. A large communication between the rectum and posterior neovagina was confirmed with the backfilled water in the rectum [Figure 1]. The defect was measured approximately 9 cm × 4 cm. The interspace between the rectal mucosa and neovaginal epithelium was carefully separated with Bovie electrocautery. Circumferential dissection was performed to separate the rectal mucosa from the underlying muscular layers. The neovaginal side of the fistula was dissected in a similar fashion to separate the epithelium from the rectal muscle and underlying fibrotic tissues. The edges of the rectal mucosa were re-approximated using absorbable sutures in an interrupted fashion after re-approximation of underlying rectal muscular layers with absorbable sutures in a running fashion. The pedicled pudendal fasciocutaneous flap was marked 3 cm in width and 9 cm in length on the left upper portion of the perineum (upside-down U-shaped), and the thigh was centered on the neolabial crural fold with a base at the perineal body. [Figure 2]a shows how the horn-shaped flap was planned with the flare of the horn at its base. The flap was made lateral to the hair-bearing area of the labia majora and was centered on the crease of the groin. To prevent disruption of the blood vessel network, careful dissection was performed to elevate the deep fascia overlying the adductor muscles, using Bovie electrocautery. The apex of Singapore fasciocutaneous axial flap was then brought into the neovaginal area. The flap was elevated just to the left side of the previous wound scar. The flap was elevated just to the left side of the previous wound scar. The skin of the neovaginal introitus proximal to the beginning of the fistula was then split just off the midline in a paramedian axial incision. The skin edges were dissected free for approximately 3-cm wide enough to allow the Singapore flap to be inset. This flap was rotated and advanced into the neovagina [Figure 2]b, and the edges of the flap were secured initially to the edges of the split neovaginal introitus epithelium, with absorbable sutures. The rest of the Singapore flap was then sutured in layers, using monofilament absorbable sutures, to the cut edges of the neovaginal epithelium. The flap provided vascularized and multilayered reinforcement over the primary repair of the rectal mucosa and helped to widen the neovagina introitus by approximately 3 cm to correct the neovaginal stricture. The donor site for the Singapore flap was repaired in layers using absorbable sutures. The neovagina was then packed loosely with metronidazole-fused vaginal packing and was secured with stitches at the introitus [Figure 3]a. The patient tolerated the procedure well.
Figure 1: Demonstration of rectoneovaginal fistula. The arrow shows leakage of backfilled water through the recto-neovagina defect

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Figure 2: Creation of fasciocutaneous Singapore (a) The horn-shaped flap was created with the flare of the horn at its base. The flap was made lateral to the hair-bearing area of the labia majora and centered on the crease of the groin. (b) The flap was rotated and advanced into the neovagina and the edges of the flap were sewn initially to the edges of the split vaginal introitus epithelium using absorbable sutures. The apex of the Singapore flap was brought into the neovagina defect and suture-secured at the apex of neovagina defect. Please note that the point “A” (the apex of the neovagina) is sewn to point “a” (the apex of the flap) and the point “B” (the upper edge of vulva skin incision) is to point “b” (the lateral-inferior edge of the flap). The rest of Singapore flap was then sutured in layers to the cut edges of the vaginal epithelium

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Figure 3: Final Presentation: (a) at the end of the surgery, (b) at 1 week postoperative visit. The blue arrow points Singapore flap inserted in the the vaginal canal. The red arrow points the donor site

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Postoperative follow-up

The patient was discharged home on the postoperative day #4. The loop ileostomy was functioning well and the surgical scar in the perineum was healing well without any signs of infection. At the 1-week postoperative visit, vaginal packing was removed. No inflammation was noted inside the neovagina or on the perineal area [Figure 3]b. At the 6-week postoperative visit, a small distal RnVF (about 1 cm in diameter) was present. Expectant management was recommended at the time, hoping that the fistula would close with diverting ostomy.


  Discussion Top


Although RnVF is uncommon, it is a challenging complication of neovaginoplasty. Predisposing factors for RnVF formation include intraoperative rectal perforation, infected neovaginal hematoma, abscesses or necrosis of the skin flap or bowel segment, revision of neovaginoplasty, and malignancy within the neovagina.[2]

Unlike well-established surgical management options for rectovaginal fistulas in natal women, surgical management for RnVF is scarce. Krege et al. described a rectal defect in 3 of 66 patients who underwent gender-reassignment surgery. One patient was treated with a free skin mesh graft with temporary colostomy and the other two were treated with a temporary colostomy. The final outcome was not reported in their study.[8] Revol et al. reported a total of 8 major complications of 63 male-to-female gender-reassignment surgeries. Among those complications, there were one rectal lesion and one posttraumatic RnVF, but the treatment utilized was not reported in their study.[9] van der Sluis et al. reported 8 RnVF cases in 1037 patients who underwent a primary vaginoplasty procedure. Five of 80 patients who had a revision vaginoplasty with full-thickness grafts, an intestinal segment, or a pedicled bilateral pudendal-thigh flap developed an RnVF. RnVF was treated with a low-residue diet, fistulectomy, primary closure, or a local advancement flap with/without fecal diversion through temporary colostomy or ileostomy.[2]

Graciloplasty (gracilis muscle interposition) has been utilized to treat difficult rectovaginal/vesicovaginal fistulas since 1928.[10] Altomare et al. described surgical technique of graciloplasty for recurrent RnVF in a male-to-female trans-sexual patient. The gracilis muscle is long enough to cover the repaired rectal lesion and to keep it separated from the neovagina by vital tissue.[7] However, complications following graciloplasty are not uncommon, infection being the most common complication.[11] Recently, buccal mucosal grafts have been reported as a surgical technique to repair RnVF. Elmer-DeWitt et al. state that thick epithelium of the buccal mucosa contributes thickness and stability to the graft and thin submucosa facilitates early revascularization. In addition, they emphasized that the buccal mucosa has excellent elasticity and causes less inflammation and scarring. However, donor-site complications can occur although most can resolve by 6 months.[12]

When Wee and Joseph first described neurovascular pudendal-thigh flaps (a.k.a. Singapore flaps), the technique was used to reconstruct the vagina in an adult after total pelvic exenteration for malignancy and in children with congenital vaginal anomalies. It is believed that the flap is simple, reliable, and sensate. In addition, the donor scars in the groin are well hidden and the reconstructed vagina has a natural angle for intercourse.[6] This case report describes a modified Singapore flap technique that utilizes a unilateral posteriorly based fasciocutaneous axial flap to manage a male-to-female trans-sexual patient with RnVF.


  Conclusion Top


It is important to manage patients with an RnVF with a multidisciplinary approach involving colorectal/plastic surgeons, urogynecologist. Vaginal reconstruction with a unilateral fasciocutaneous Singapore flap can be considered for male-to-female trans-sexual patients with a complex RnVF as it provides excellent neovascularization with a sensate flap and desirable cosmetic outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The author gratefully acknowledges Dr. Randolph Steinhagen: Professor of Surgery specialized in Surgery, Colon and Rectal Surgery, Proctology at Mount Sinai Medical Center/Icahn School of Medicine, New York, NY, Untied States, and Dr. Jess Ting: Assistant Professor of Plastic Surgery, specialized in Transgender Medicine and Surgery Institute for Advanced Medicine at Mount Sinai Medical Center/Icahn School of Medicine, New York, NY, United States, for developing surgical management plans and providing excellent surgical skills and support to this case report.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sigurjonsson H, Rinder J, Möllermark C, Farnebo F, Lundgren TK. Male to female gender reassignment surgery-surgical outcomes of consecutive patients during 14 years. JPRAS Open 2015;6:69-73. [doi: 10.1016/j.jpra.2015.09.003].  Back to cited text no. 1
    
2.
van der Sluis WB, Bouman MB, Buncamper ME, Pigot GL, Mullender MG, Meijerink WJ, et al. Clinical characteristics and management of neovaginal fistulas after vaginoplasty in transgender women. Obstet Gynecol 2016;127:1118-26.  Back to cited text no. 2
    
3.
Reichert M, Schwandner T, Hecker A, Behnk A, Baumgart-Vogt E, Wagenlehner F, et al. Surgical approach for repair of rectovaginal fistula by modified martius flap. Geburtshilfe Frauenheilkd 2014;74:923-7.  Back to cited text no. 3
    
4.
Woods JE, Alter G, Meland B, Podratz K. Experience with vaginal reconstruction utilizing the modified Singapore flap. Plast Reconstr Surg 1992;90:270-4.  Back to cited text no. 4
    
5.
Fein LA, Salgado CJ, Pearson JM. Singapore flap (pudendal thigh fasciocutaneous flap) for vaginal reconstruction. In: Tran TA, Panthaki Z, Hoballah J, Thaller S, editors. Operative Dictations in Plastic and Reconstructive Surgery. Switzerland: Springer International Publishing; 2017. p. 617-9.  Back to cited text no. 5
    
6.
Wee JT, Joseph VT. A new technique of vaginal reconstruction using neurovascular pudendal-thigh flaps: A preliminary report. Plast Reconstr Surg 1989;83:701-9.  Back to cited text no. 6
    
7.
Altomare DF, Scalera I, Bettocchi C, Di Lena M. Graciloplasty for recurrent recto-neovaginal fistula in a male-to-female transsexual. Tech Coloproctol 2013;17:107-9.  Back to cited text no. 7
    
8.
Krege S, Bex A, Lümmen G, Rübben H. Male-to-female transsexualism: A technique, results and long-term follow-up in 66 patients. BJU Int 2001;88:396-402.  Back to cited text no. 8
    
9.
Revol M, Servant JM, Banzet P. Surgical treatment of male-to-female transsexuals: A ten-year experience assessment. Ann Chir Plast Esthet 2006;51:499-511.  Back to cited text no. 9
    
10.
Garlock JH. The cure of an intractable vesicovaginal fistula by the use of pedicled muscle flap. Surg Gynecol Obstet 1928;47:255.  Back to cited text no. 10
    
11.
Madoff RD. Surgical treatment options for fecal incontinence. Gastroenterology 2004;126:S48-54.  Back to cited text no. 11
    
12.
Elmer-DeWitt MA, Wood HM, Hull T, Unger CA. Rectoneovaginal fistula in a transgender woman successfully repaired using a buccal mucosa graft. Female Pelvic Med Reconstr Surg 2019;25:e43-4.  Back to cited text no. 12
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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