If this blog post sounds fishy, you’re right!
Increasingly, surgeons such as Dr. Bowers are being asked to create adult genitalia from infantile tissues. There also have long been patients who end up with suboptimal depth—often from other surgeons but also patients of Dr. Bowers who lack sufficient pre-operative skin in order to create functional vaginas. The maturation of a large number of children, genitalia growth blocked prior to the onset of puberty, now coming to the age of surgery, is putting an enormous strain on Dr. Bowers and those who care for these adolescents and young adults as they seek functional genitalia. All vaginas require a lining of some sort. Otherwise, surgeons can create the vaginal space but, if unlined with some sort of skin, the area will be simply a raw hole that will usually close itself off.
To date, the options for patients have been limited to traditional human linings of the area, aggressive tissue mobilization or use of very expensive donor graft material (Repliform, DermaPure, Alloderm, Integra). Jazz Jennings (via the TLC show, “I am Jazz”) was the most public example of how this can be a challenge. Fortunately, Jazz benefited from a newer technique whereby the abdominal sac (peritoneum) can be used to harvest a portion of itself for the purposes of lining the vagina and received excellent depth. Unfortunately, harvesting of the peritoneum is expensive, somewhat risky, invasive (it is done via laparoscopy) and not available everywhere surgeons perform vaginoplasty procedures. Furthermore, Jazz’ limited amounts of skin put strain on other portions of her tissues in the region causing her to have an second (albeit, unhelpful) operation and then still a 3rd operation to achieve an acceptable result.
As a result of these challenges, Dr. Bowers has been on the search for new and innovative methods of achieving adequate results for females AMAB when skin is limited or revisions are needed without relying exclusively on peritoneum. One of the better additions to Dr. Bowers’ options was use of the tunica vaginalis. While not a large amount of skin (usually less than 3 cm by 8 cm), the tunica vaginalis is actually peritoneum—stomach sac that is pushed out of the body cavity though the inguinal ring when the testes push into the scrotum embryology. In other words, all patients with descended testicles have tunica vaginalis as an option. This does not make a huge difference but can assist borderline cases where skin is limited.
But, clearly, additional resources are needed and new ideas welcome. Dr. Bowers has been asked and has become aware of Tilapia skin, for example, used to create neovaginal lining in vaginoplasties for females AMAB in Brazil. Good fortune allowed Dr. Bowers during her birthday week to visit Dr. Alvaro Rodriguez in Cali, Colombia. Dr. Rodriguez learned the tilapia technique while training in Brazil and now employs this new method for his patients with limited potential vaginal skin. He indicates he will be presenting preliminary data at the upcoming WPATH meeting in 2020. While visiting with Dr. Bowers in California, Dr. Rodriguez was able to share some of his information and experience with the technique including a surgical video. While not yet available commercially, we are anxious to hear more of the technique and will be among the early utilizers, based upon early reports of the technique.