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Male-to-Female Gender-Affirming Surgery Using Nile Tilapia Fish Skin as a Biocompatible Graft
Abstract
Study Objective
Insufficient penile skin is common during vaginoplasty for male-to-female transition. This issue may be compensated via a scrotal skin flap, with the drawback of hair growth [1]. In recent studies, Nile tilapia skin was successfully used for surgical management of Mayer-Rokitansky-Küster-Hauser syndrome [2,3] and vaginal stenosis [4,5]. The present study aims to describe a novel technique for primary vaginoplasty in male-to-female gender-affirming surgery using Nile tilapia skin as a biocompatible graft to assure adequate vaginal depth.
Design
Stepwise demonstration of the procedure with narrated video footage.
Setting
Transgender health clinic.
Interventions
A 29-year-old patient with gender dysphoria was referred to our office due to desire for gender-affirming surgery. Physical examination revealed normal male genitalia with a 14 cm long penis. Before surgery, Institutional Review Board approval and written permission from the patient were obtained. After orchiectomy, penile disassembly, perineal dissection, and urethroplasty were performed, a hollow Nile tilapia skin mold was prepared and sutured to the distal edge of the remaining penile skin. This structure was inverted, covering the newly created canal. The neocavity was then filled with a handmade inflatable vaginal mold, held in place by sutures in the labia majora. Finally, labiaplasty and clitoroplasty were conducted. After 7 days, the inflatable mold was removed and use of progressively larger dilators was initiated. After 3 weeks, a neovagina 16 cm long and able to accommodate the width of two fingers was detected. At that time, Nile tilapia skin was completely reabsorbed into the neovaginal mucosa. There were no complications in the early post-surgical period.
Conclusion
Nile tilapia skin, a safe, low cost and easy-to-use biocompatible material, may be an alternative option to scrotal skin grafts for neovaginal augmentation in primary vaginoplasty for male-to-female gender transition. However, further studies are needed to confirm this assertive.
... Para Rodríguez et al. (2020), a pele peniana insuficiente é comum durante a vaginoplastia quando é realizada a cirurgia de para transição de homem para mulher, e esse problema pode ser compensado por um retalho cutâneo escrotal, com a desvantagem do crescimento de pelos. Para os autores, a pele da tilápia do Nilo foi utilizada com sucesso para o tratamento cirúrgico da síndrome de Mayer-Rokitansky-Küster-Hauser e da estenose vaginal. ...
... Segundo Lantis et al. (2023), as úlceras no pé diabético (DFUs) continuam sendo causa de morbidade significativa. Conforme os especialistas, este foi o terceiro de três artigos planejados que relataram um estudo prospectivo, multicêntrico, randomizado e controlado que avaliou o uso de enxerto de pele de peixe (FSG) acelular rico em ômega-3 em comparação com o atendimento padrão (CAT) no tratamento de DFUs. ...
Introdução: A utilização da pele de peixe em cirurgias plásticas reconstrutivas representa uma abordagem inovadora e promissora. O uso de pele de peixe, como a proveniente do tilápia, vem ganhando destaque devido à sua composição rica em colágeno, propriedades biocompatíveis e baixo risco de rejeição. Objetivo: Realizar uma revisão da literatura buscando sintetizar as evidências relacionadas à utilização da pele de peixe em cirurgia plástica reconstrutiva. Método: A base de dados PUBMED foi utilizada para seleção dos trabalhos, empregando a seguinte estratégia de busca: (fish[title] AND skin[title]) AND (plastic OR esthetic OR aesthetic OR reconstructive OR reconstruction). Apenas ensaios clínicos, estudos observacionais e relatos de caso publicados nos últimos 10 anos foram incluídos na amostra de artigos a serem avaliados. Resultados: A busca foi realizada no mês de outubro de 2023, e a estratégia previamente estabelecida retornou 11 artigos. Após a leitura dos títulos e resumos, 2 artigos foram eliminados, sendo um deles por ter sido realizado em animais, e outro por se caracterizar como uma proposta de ensaio clínico ainda não finalizada. Sendo assim, 9 artigos compuseram a amostra final desta revisão. Conclusão: No geral, os estudos revisados apontaram que a utilização da pele de peixe em cirurgias reconstrutivas mostrou-se como uma opção segura e confiável. Dentre os principais resultados, destacou-se a utilização da pele de peixe no tratamento e aceleração da recuperação de feridas em pés diabéticos, feridas decorrentes do processo de calcifilaxia, e na abordagem terapêutica para angiodermatite necrótica. Interessante destacar o uso da pele de peixe na criação de neovaginas, com a utilização da pele de tilápia do Nilo no tratamento da síndrome de Mayer-Rokitansky-Küster-Hauser em pacientes que não obtiveram sucesso com a terapia de dilatação, na estenose vaginal e na vaginoplastia primária nos casos de transição de gênero masculino-feminino. No entanto, cabe ressaltar a importância do cuidado com o material a ser transplantado, que deve ser esterilizado de forma eficaz, especialmente com a utilização de nanopartículas de prata.
... Allografts and xenografts have been described for use in neovaginal lining. Rodriguez et al. [53] report using Nile tilapia fish skin: in this technique, the fish skin xenograft is tubularized and sutured to the penile skin tube, akin to a scrotal graft in PIV. Reported histologic analysis of the lining 6 months post-operatively revealed a hyperplastic epithelial lining similar to that of a natal vagina [54]. ...
Gender-affirming vaginoplasty (GAV) comprises the construction of a vulva and a neovaginal canal. Although technical nuances of vulvar construction vary between surgeons, vulvar construction is always performed using the homologous penile and scrotal tissues to construct the corresponding vulvar structures. Therefore, the main differentiating factor across gender-affirming vaginoplasty techniques is the tissue that is utilized to construct the neovaginal canal. These tissue types vary markedly in their availability, histology, and ease of harvest and have different advantages and disadvantages to their use as neovaginal lining. In this narrative review, the authors provide a comprehensive overview of the tissue types and associated operative approaches used for construction of the neovagina in GAV. Tissue choice is guided by several factors, such as histological similarity to natal vaginal mucosa, tissue availability, lubrication potential, additional donor site morbidity, and the specific goals of each patient. Skin is used to construct the neovagina in most cases with a combination of pedicled penile skin flaps and scrotal and extra-genital skin grafts. However, skin alternatives such as peritoneum and intestine are increasing in use. Peritoneum and intestine are emerging as options for primary vaginoplasty in cases of limited genital skin or revision vaginoplasty procedures. The increasing number of gender-affirming vaginoplasty procedures performed and the changing patient demographics from factors such as pubertal suppression have resulted in rapidly evolving indications for the use of these differing vaginoplasty techniques. This review sheds light on the use of less frequently utilized tissue types described for construction of the neovaginal canal, including mucosal tissues such as urethral and buccal mucosa, the tunica vaginalis, and dermal matrix allografts and xenografts. Although the body of evidence for each vaginoplasty technique is growing, there is a need for large prospective comparison studies of outcomes between these techniques and the tissue types used to line the neovaginal canal to better define indications and limitations.
... As células-tronco podem ser administradas diretamente na área da lesão ou ao redor dela, onde elas se diferenciam em diversos tipos celulares que desempenham papel na regeneração dos tecidos (BEHEREGARAY et al., 2017). -JÚNIOR et al., 2020;RODRÍGUEZ et al., 2020). ...
Este trabalho de revisão de literatura apresenta uma análise abrangente sobre os principais tipos de terapias não convencionais utilizadas no manejo de feridas, além de explorar os princípios básicos da cicatrização de feridas. Destaca-se a importância crucial da limpeza e desbridamento adequados das feridas para uma cicatrização eficaz, juntamente com diferentes abordagens terapêuticas, como tratamento por primeira, segunda e terceira intenção. O estudo também investiga terapias não convencionais, como laserterapia, uso de células-tronco e membranas biológicas, fornecendo detalhes sobre seus mecanismos de ação e evidências de eficácia em estudos experimentais e clínicos. Ao concluir, ressalta-se a necessidade contínua de avanços na área e a importância de pesquisas adicionais para avaliar a eficácia e segurança dessas terapias alternativas. Em síntese, este trabalho oferece uma visão atualizada e abrangente sobre a cicatrização de feridas, fornecendo insights valiosos sobre as opções terapêuticas disponíveis para promover a recuperação dos tecidos lesionados.
... It allows tissue repair and serves as a physical barrier in addition to preventing dehydration, sepsis, and metabolic and functional complications (Boateng and Catanzano, 2015;Inoue et al., 2016;Lineen and Namias, 2008). The use of tilapia skin has transcended its application in burns and is also used in other soft tissue reconstructive surgeries, such as neovaginoplasty (Bezerra et al., 2018;Dias et al., 2020;Pinto Medeiros Dias et al., 2019) and male-to-female gender-affirming surgery (Rodríguez et al., 2020). ...
Nile tilapia (Oreochromis niloticus) skin is a well-known biomaterial used as an occlusive dressing for burn treatment. It is also an inexpensive and important source of collagen. This study aims to describe the ultrastructural aspects of Nile tilapia skin, assess its collagen amount and organization, and compare quantitative methods of histochemical and immunohistochemical analysis (in all sterilization steps for use in burn dressings). One sample (0.5 × 0.5 cm) of ten different fish skins was divided in four groups: in natura skin (IN), chemical sterilization (CH), additional irradiation (30 kGy) (IR), and skins used in burn treatment (BT) to compare histochemical and immunohistochemical findings of collagen amount and describe ultrastructural aspects through scanning electron microscopy. The amount of type I collagen decreased during sterilization and clinical use owing to gradual reduction of immunostaining (anti-collagen-I) and decreasing fiber thickness of the collagen, when compared to type III (Picrosirius-red-polarized light). The collagen fibers were rearranged at each sterilization step, with a low collagen percentage and large structural disorganization in BT. The amount of type-I collagen was further reduced after BT (p < 0.05). Both the methods did not exhibit a quantified value difference (p = 0.247), and a positive correlation (r = 0.927; 95 % CI = 0.720–0.983) was observed between them, with concordance for collagen quantification in similar samples, presenting a low systematic error rate (Dalberg coefficient: 6.70). A significant amount of type-I collagen is still observed despite sterilization, although clinical application further reduces type I collagen. Its quantification can be performed both by immunohistochemistry and/or Picrosirius Red reliably.
... Zhang et al., 2019;Zhu et al., 2020). Moreover, recently, it was reported that tilapia skin had been used in maleto-female gender-affirming surgery or deep second-degree burns treatment in clinic Rodríguez et al., 2020). Besides, the decellularized sturgeon cartilage ECM applications do not raise any cultural or religious concerns compared with that derived from porcine and mammals (Easterbrook & Maddern, 2008;Salvatore et al., 2020). ...
Since chondrocyte hypertrophy greatly limits the efficiency of cartilage defects repairing via cartilage tissue engineering (CTE), it is critical to develop a functional CTE scaffold able to inhibit chondrocyte hypertrophy during this period of cartilage regeneration. In this study, we tested the applicability of using decellularized sturgeon cartilage ECM (dSCECM) scaffold to cease chondrocyte hypertrophy during cartilage damage repair. The dSCECM scaffolds with interconnected porous structure and pore size of 114.1 ± 20.9 μm were successfully prepared with freeze-dry method. Chondrocytes displayed a round shape and aggregated to form cellular spheroids within dSCECM scaffolds, which is similar to their chondrocytic phenotype within cartilage in vivo. Higher transcriptional level of chondrogenic related genes and integrin related genes was observed in chondrocytes incubated with dSCECM scaffolds instead of type I collagen (COL I) scaffolds, which were used as the control due to their widely usage in CTE and clinic applications. Furthermore, it confirmed that, compared with COL I scaffolds, dSCECM scaffolds significantly reduced the transcription of chondrocyte hypertrophy related genes in chondrocytes following the hypertrophic induction treatment. To test the ability of dSCECM scaffold to inhibit chondrocytes hypertrophy in vivo, chondrocytes with dSCECM scaffolds and COL I scaffolds were cultured with hypertrophic media and were implanted into nude mice respectively. Following 4 weeks implantation, interestingly, only the specimens derived from COL I scaffolds displayed consequences of chondrocyte hypertrophy like calcification deposition, demonstrating that chondrocyte hypertrophy is ceased by the dSCECM scaffold following hypertrophic induction. It suggests that the dSCECM scaffold can be potentially applied in clinical treating cartilage defects via the CTE approach to avoid the risk of chondrocyte hypertrophy.
Introduction
Bioengineered acellular fish skin matrix (BAM) is a highly engineered derivation of natural fish skin (NFS) and is occasionally used in the United Kingdom (UK) National Health Service (NHS) to treat severe thermal burns and other wounds that are refractive to therapies. However, NFS, with its collagenous and regenerative properties, has been used successfully in Brazil and other low- and middle-income countries as a material for skin grafts and occlusive dressings in partial thickness burns, and also as a skin replacement graft in some clinical scenarios (e.g. vaginoplasty). Given their common derivation, and potential use in similar clinical settings, this review is a comparative analysis of the health outcomes and costs of both BAM and NFS, and discusses NFS’s potential suitability for the NHS.
Method
A systematic search was conducted using six databases to identify peer-reviewed literature on NFS and BAM use in burn therapy. Two independent reviewers employed Covidence for research selection and data extraction. The Cochrane Risk of Bias Tool was used to assess research quality and bias risk. A narrative synthesis approach was employed due to the varied outcomes examined.
Results
Despite studies using different outcome measures on different burn types, 14 studies investigating the use of NFS and/or fish-skin derived BAM for burn treatment were included. Studies utilizing NFS demonstrated favorable outcomes for pain reduction, re-epithelialization time, and healing time, and these were comparable to fish skin-derived BAM. Moreover, NFS exhibited significantly lower costs, approximately $11 per patient, making it a potentially cost-effective alternative to BAM, which is several hundred times more expensive.
Discussion
NFS shows promise as a viable option for partial thickness burn treatments in the UK, presenting comparable outcomes to fish skin-derived BAM. The significantly lower cost of NFS suggests potential economic benefits for implementation within the NHS. Although fish skin-derived BAM is used predominantly for full-thickness burns, NFS offers significantly greater cost-benefit profile for partial thickness burns, with even some evidence for full thickness burn treatment given its recent application in vaginoplasty, i.e. as a dermal replacement. However, further research, including comparator trials, feasibility studies, and assessments of acceptability, is necessary to explore the full potential of NFS in UK healthcare settings. Whether or not NFS is considered a xenotransplant in the UK will need further examination as well as a clear pathway to regulatory approval, beginning with well evaluated pilot studies in the UK within appropriate Research Ethics Committee approvals.
Conclusion
NFS demonstrates promise as a viable burns treatment option, offering substantial economic savings compared to current treatments. Further research is warranted to evaluate its effectiveness and acceptability.
Purpose of review
The present study reviews contemporary literature focused on uterine transplantation and tissue substitutes for the purposes of transfeminine genital gender affirming surgery (GAS). Additional background is provided for both topics to provide a more comprehensive understanding of the modern applications.
Recent findings
Uterine transplant remains an experimental procedure in cisgender patients who wish to avoid surrogacy. A natural extension might be to apply these techniques to GAS. Technical barriers include anatomic differences and alterations to gender-affirming hormone administration protocols. Ethically, resource allocation, elective immunosuppression, societal response to organ donation, legal ramifications of parenthood as well as the potential, under-studied effects that such an elective procedure may have on the patient's offspring must be further investigated.
Tissue substitutes have long been used in urologic reconstruction but more recently applied to gender affirmation surgery which has traditionally relied on autografting to line the neovaginal canal both in the context of primary and revision vaginoplasty. However, the advent of off-the-shelf xenografts have recently been posited to be safe and efficacious alternatives to autografts. Longer term studies are needed to validate whether these proposed methods are indeed noninferior to traditional approaches.
Summary
The field of feminizing gender affirmation surgery remains an exciting frontier for surgeons and patients alike. Given the relative nascency of the specialty and its propensity to draw techniques from various surgical disciplines there exists a unique opportunity for rapid innovation to overcome challenging problems posed by these complex procedures as evidenced by discussions around applying uterine transplantation and the use of novel tissue grafting techniques.
Background:
Tilapia skin has already been used in various medical scenarios, but there are no studies showing the use of tilapia skin for hand reconstruction in Apert syndrome. The objective of this study is to determine whether the use of tilapia skin during graft bed preparation for children with Apert syndrome can shorten wound reepithelialization intervals, reduce the number of dressing changes, and decrease patient discomfort.
Methods:
This is a prospective study on consecutive patients with Apert syndrome who underwent hand reconstruction at our Hospital. Patients were divided into 2 groups: (1) a control group consisting of patients who underwent conventional digit separation hand reconstruction surgery (2) an experimental group consisting of patients who underwent similar digit separation hand reconstruction surgery that commenced with the placement of a thin layer of tilapia skin at the raw commissures during a first operation, which was subsequently replaced by an autologous skin graft during a second operation staged 10 days postoperatively. Pain assessment was performed using the Visual Analog Scale. The number of dressing changes was also assessed. A T test compared the total number of dressings changes and pain data.
Results:
Experimental group patients (n = 8) required an average of 9.4 days of daily dressing changes, and control group patients (n = 5) required an average of 20.8 days of daily dressing changes (P < 0.05) and tended to experience significantly less pain when compared with patients in the control group (P = 0.079).
Conclusion:
Tilapia skin can shorten wound reepithelialization intervals by reducing the total number of dressing changes.
Feminizing genital surgery for transgender women is a feasible and fulfilling intervention in alleviating gender dysphoria. Several techniques in neovaginal creation can be offered, including vulvoplasty, penile skin inversion vaginoplasty, peritoneal vaginoplasty, and enteric vaginoplasty. Complication rates are low and often managed conservatively. Favorable sexual function outcomes indicate high satisfaction rates.
Background:
Vaginoplasty is a gender affirming procedure for transgender and gender diverse (TGD) patients who experience gender incongruence. This procedure reduces mental health concerns and enhances patients' quality of life. A systematic review investigating the sexual health outcomes of vaginoplasty has not been performed.
Objectives:
To investigate sexual health after gender-affirming vaginoplasty for TGD patients. Data Sources MEDLINE/PubMed, Embase, Scopus and PsycINFO databases were searched, unrestricted by dates or study design.
Methods:
We included primary literature that incorporated TGD patients, reported sexual health outcomes after vaginoplasty intervention and were available in English. Outcomes included at least one of these sexual health parameters: sexual desire, arousal, sensation, activity, secretions, satisfaction, pleasure, orgasm, interferences or aids.
Results:
Our search yielded 140 studies with 12 different vaginoplasty surgical techniques and 6,953 patients. The majority of these studies were cross-section or retrospective cohort observational studies (66%). 17.4 - 100% (median 79.7%) of patients (n = 2,384) were able to orgasm postoperatively regardless of revision or primary vaginoplasty techniques. Female Sexual Function Index was the most used standardized questionnaire (17 studies, ranging from 16.9 - 28.6). 64 - 98% (median 81%) of patients were satisfied with their general sexual satisfaction. The most common interference of sexual activity was dyspareunia.
Conclusions:
The heterogenous methods of measuring sexual outcomes reflects the difficulty in comparing single-center surgical outcomes, encouraging the need for a standardized and validated metric for reporting sexual health after vaginoplasty for TGD patients. The most common sexual health parameter reported is sexual activity while therapeutic aids and pleasure were the least reported parameters. Future studies are needed to improve and expand methods of measuring sexual health, including prospective studies, validated questionnaires and inclusive metrics.
Objective
To describe a new technique of neovaginoplasty after a female gender reassignment surgery using a Tilapia fish skin as a graft.
Design
Stepwise demonstration of a new technique with narrated video of a single case report. The patient has given oral and written informed consent. Moreover, this video report is part of a multicenter, IRB-approved study.
Setting
A Women´s University Hospital, in Campinas, Brazil.
Interventions
Neovaginoplasty technique using Tilapia fish skin with key strategies: (1) corpus cavernosum removal; (2) vagina tunnel creation; (3) mold coating with Tilapia fish skin, (4) mold fixation; (5) postoperative care. The patient remained with the mold coated with tilapia fish skin for 5 days, after this time the mold was removed and the tissue graft was adhered and incorporated in the new vaginal canal. After 2 months the tissue resembled a vaginal mucosa and the vaginal length was 8 cm. The patient has not had intercourse yet.
Conclusion
We introduce an alternative for low morbidity neovaginoplasty based on the experience of plastic surgery in burned grafts. The procedure described offered an alternative option of an anatomic neovagina similar to mucosa tissue, by a means of a simple, low morbidity and minimally invasive procedure.
Gender affirmation surgery is paramount in the treatment of gender dysphoria for transgender individuals. For transgender women, vaginoplasty offers the opportunity for removal of masculine-appearing genitalia and replacement with a gender-congruent appearance. While numerous techniques have been described in the past, approaches have standardized considerably. Herein, we describe a technique to penile inversion vaginoplasty and focus on some of the critical steps of the procedure to try to optimize patient outcomes. We also review relevant literature regarding perioperative outcomes.
Objective:
To describe a McIndoe procedure technique for surgical management of Mayer-Rokitansky-Kuster-Hauser syndrome with the use of Nile tilapia skin as a scaffold for the proliferation of new vaginal epithelium.
Design:
Surgical video article. Local Institutional Review Board approval and written permission from the patient were obtained. There were no conflicts of interest.
Setting:
University hospital.
Patient(s):
A 17-year-old woman who presented at our gynecology department with the complaint of primary amenorrhea. At physical examination, she had a phenotypically normal vulva with no vaginal canal. Magnetic resonance imaging of the abdomen and pelvis revealed normal ovaries and absence of uterus and vaginal canal. No other congenital malformations were found. Karyotype was 46,XX.
Intervention(s):
The McIndoe procedure involved only a vaginal approach. Labia minora were separated, and a transverse midline incision of 3 cm was made. The vesicorectal space was progressively dissected. Blunt dissection was performed initially with digital separation of tissues. The neovagina was then inspected with the introduction of a vaginal speculum, allowing for review of hemostasis. Blunt dissection was continued with the aid of the speculum, to reach the appropriate vaginal dimensions. Subsequently, a vaginal acrylic mold covered with two pieces of processed and sterilized tilapia fish skin was inserted and accommodated into the newly created cavity. The external side of the tilapia skin, which maintained its grayish coloration after the removal of the scales, stayed in contact with the acrylic mold, while the white internal side of the tilapia skin, which was previously attached to the fish's muscle, stayed in contact with the walls of the neocavity. The mold was held in position by four multifilament polyglactin 1.0 sutures in the labia majora, thus preventing expulsion.
Main outcome measure(s):
Anatomic data, such as measurement of the final canal length, and histomorphologic analysis, 180 days after surgery.
Result(s):
The patient remained on bed rest for 9 days, after which the tilapia fish skin had been partially reabsorbed. After this time, the acrylic mold was removed. A larger plastic mold was then inserted and the patient was advised to wear it day and night for the first postoperative month. The vaginal mold had to be worn each night until normal sexual intercourse was possible. The final canal length 180 days after surgery was between 8 and 9 cm. For the histopathologic analysis, fragments of the lateral vaginal wall were removed 180 days after surgery and showed the presence of stratified squamous epithelium with five cell layers, ectasic blood vessels, and occasional desquamated epithelial cells.
Conclusion(s):
The procedure described offered this patient an anatomic and functional neovagina by means of a simple, safe, easy, effective, quick, and minimally invasive procedure. Limitations include the experimental nature of this study, based on a single case report with no long-term outcome results. The tilapia fish skin is a low-cost and widely available biomaterial.
José Frota Institute (IJF) -Rua Barão do Rio Branco, 1816, Centro -60025-061 -Fortaleza, Brazil. Phone number: +55
- Burn Treatment
- Dr Center
Burn Treatment Center, Dr. José Frota Institute (IJF) -Rua Barão do Rio Branco,
1816, Centro -60025-061 -Fortaleza, Brazil. Phone number: +55 85 3255-5000.
Neovaginoplasty using Nile Tilapia Fish Skin as a new biological graft in patients with Mayer-Rokitansky-Küster-Hauser syndrome
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Tilapia Fish Skin for Neovaginoplasty after Gender Reassignment Surgery
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