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Buccal Mucosa

Transgirldiaries provides a great infographic and a good set of links (replicated below) that discusses the use of Buccal (inner cheek) mucosa skin grafts for forming the neovagina in MTF trans patients.

  • Wagner2010 Wagner S, Greco F, Hoda MR, Inferrera A, Lupo A, Hamza A, Fornara P: Male-to-Female Transsexualism: Technique, Results and 3-Year Follow-Up in 50 Patients. Urol Int 2010;84:330-333
  • Wood2004 Wood, DN and Allen, SE and Andrich, DE and Greenwell, TJ and Mundy, AR (2004) The morbidity of buccal mucosal graft harvest for urethroplasty and the effect of non-suture of the graft harvest site on post operative pain. In: Journal of Urology. (pp. 580 - 583).
  • Lin01032003 Lin, W.C. and Chang, Cherry Y.Y. and Shen, Y.Y. and Tsai, H.D., Use of autologous buccal mucosa for vaginoplasty: a study of eight cases, V18, No. 3, pages 604-607, 2003, journal: Human Reproduction
BACKGROUND: Vaginal agenesis is a rare condition and treatment methods are varied. The difference between most of the surgical techniques is the graft material used. The purpose of this study was to describe the procedure and outcome of creating a neovaginal pouch lined with autologous buccal mucosa.
METHODS AND RESULTS: Between August 2000 and February 2002, eight patients with Mayer-Rokitansky-Kuster-Hauser syndrome were admitted to our hospital. All of the patients successfully underwent neovaginoplasty with autologous buccal mucosa as graft material. The buccal mucosal wound completely healed 2 weeks after the operation and the neovaginal length and calibre were well formed. Follow-up ranged from 0.5 to 1.5 years. One patient encountered post-operative vaginal bleeding and another patient suffered from urinary bladder injury.
CONCLUSION: This is the first reported procedure of vaginoplasty with autologous buccal mucosa as graft material. Our method is ideal in its simplicity, provides good cosmetic results, and improves the vaginal length of the patient.
  • Perovic2000 Perovic, S., Stanojevic, D. and Djordjevic, M. (2000), Vaginoplasty in male transsexuals using penile skin and a urethral flap. BJU International, 86: 843–850. doi: 10.1046/j.1464-410x.2000.00934.x
  • Bhargava2004 Bhargava, S., Chapple, C., Bullock, A., Layton, C. and MacNeil, S. (2004), Tissue-engineered buccal mucosa for substitution urethroplasty. BJU International, 93: 807–811. doi: 10.1111/j.1464-410X.2003.04723.x
  • Weyers2009 Weyers, Steven and Verstraelen, Hans and Gerris, Jan and Monstrey, Stan and dos Santos Lopes Santiago, Guido and Saerens, Bart and De Backer, Ellen and Claeys, Geert and Vaneechoutte, Mario and Verhelst, Rita, Microflora of the penile skin-lined neovagina of transsexual women, BMC Microbiology, V9, 2009, No. 1, pages 102, DOI: 10.1186/1471-2180-9-102, PubMedID: 19457233, ISSN: 1471-2180
BACKGROUND:The microflora of the penile skin-lined neovagina in male-to-female transsexuals is a recently created microbial niche which thus far has been characterized only to a very limited extent. Yet the knowledge of this microflora can be considered as essential to the follow-up of transsexual women. The primary objective of this study was to map the neo-vaginal microflora in a group of 50 transsexual women for whom a neovagina was constructed by means of the inverted penile skin flap technique. Secondary objectives were to describe possible correlations of this microflora with multiple patients' characteristics, such as sexual orientation, the incidence of vaginal irritation and malodorous vaginal discharge.
RESULTS:Based on Gram stain the majority of smears revealed a mixed microflora that had some similarity with bacterial vaginosis (BV) microflora and that contained various amounts of cocci, polymorphous Gram-negative and Gram-positive rods, often with fusiform and comma-shaped rods, and sometimes even with spirochetes. Candida cells were not seen in any of the smears.On average 8.6 species were cultured per woman. The species most often found were: Staphylococcus epidermidis, Streptococcus anginosus group spp., Enterococcus faecalis, Corynebacterium sp., Mobiluncus curtisii and Bacteroides ureolyticus. Lactobacilli were found in only one of 30 womenThere was no correlation between dilatation habits, having coitus, rinsing habits and malodorous vaginal discharge on the one hand and the presence of a particular species on the other. There was however a highly significant correlation between the presence of E. faecalis on the one hand and sexual orientation and coitus on the other (p = 0.003 and p = 0.027 respectively).Respectively 82%, 58% and 30% of the samples showed an amplicon after amplification with M. curtisii, Atopobium vaginae and Gardnerella vaginalis primer sets.
CONCLUSION:Our study is the first to describe the microflora of the penile skin-lined neovagina of transsexual women. It reveals a mixed microflora of aerobe and anaerobe species usually found either on the skin, in the intestinal microflora or in a BV microflora.
  • Lindbergh2011 Tio till femton flickor fˆds utan vagina (English: Ten to fifteen girls are born with no vagina) Article in published January 23, 2011 09:27 Translated text of article
  • Saraf2007 S. Saraf & P. Saraf : McIndoe Vaginoplasty: Revisited . The Internet Journal of Gynecology and Obstetrics. 2007 Volume 6 Number 2
  • Bekerecioglu2008 Arch Gynecol Obstet. 2008 Jun;277(6):551-4, Adaptation process of the skin graft to vaginal mucosa after McIndoe vaginoplasty, Bekerecioglu M, Balat O, Tercan M, Karakok M, Ugur MG, Isik D., Faculty of Medicine, Department of Plastic Reconstructive and Aesthetic Surgery, Gaziantep University, Gaziantep, Turkey. PMID: 18317785
OBJECTIVE: There are many methods of treatment of vaginal agenesis.
METHODS: In this study, patients who underwent McIndoe vaginoplasty were evaluated for development of vaginal mucosa. Vaginal pH measurements, smears, and punch biopsies were obtained from seven patients postoperatively at 3, 6, and 12 months after having McIndoe vaginoplasty.
RESULTS: Neovaginal smears indicated no specific data for mucosal development at the 3rd and 6th month after the operation. However, Doderlein bacilli were determined at the 12th month. Histopathological examination of punch biopsies revealed dermal and subdermal thickening at the 3rd month, partial adaptation to mucosa at 6th month, and full adaptation to mucosa at 12th month. Also normal vaginal pH levels were recorded at the 12th month.
CONCLUSION: As a result of the adaptation process, the split thickness skin graft acquired both histological and physiological characteristics of normal vaginal mucosa. Also, neovaginal epithelium was evaluated to be macroscopically similar to normal vaginal mucosa, 12 months after the operation.
  • Morcel2008 J Gynecol Obstet Biol Reprod (Paris). 2008 Oct;37(6):539-46. Epub 2008 Aug 23, The Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome: clinical description and genetics, Morcel K, Guerrier D, Watrin T, Pellerin I, Levêque J, CNRS UMR 6061 génétique et développement, IFR140 GFAS, faculté de médecine, université de Rennes-1, Rennes, France., PMID: 18723299.
The Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is characterized by congenital aplasia of the uterus and the upper part (two-third) of the vagina. It may be isolated (type I) or associated with other malformations (type II or MURCS association). These latter involve the upper urinary tract, the skeleton and, to a lesser extent, the otologic sphere or the heart. The incidence of MRKH syndrome has been estimated as 1 in 4500 women. The prime feature is a primary amenorrhea in women presenting otherwise with normal development of secondary sexual characteristics and normal external genitalia. However, the vagina is reduced to a vaginal dimple with variable depth. The ovaries are normal and functional as well as the endocrine status. Karyotype is 46,XX, with no visible chromosome modification. The phenotypic manifestations of MRKH syndrome overlap with various other syndromes or malformations and thus require accurate delineation as well as differential diagnosis. For a long time, the syndrome has been considered as a sporadic anomaly, but increasing familial cases now support the hypothesis of a genetic cause currently under investigation. The syndrome appears to be transmitted as an autosomal dominant trait with incomplete penetrance and variable expressivity.
  • Sultan2009 Gynecol Endocrinol. 2009 Jan;25(1):8-11, Mayer-Rokitansky-Kuster-Hauser syndrome: recent clinical and genetic findings, Sultan C, Biason-Lauber A, Philibert P., Unite d'Endocrinologie-Gynecologie Pediatriques, Service de Pediatrie I, Hopital Arnaud de Villeneuve, CHU Montpellier, Montpellier, France., PMID: 19165657
Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is characterized by Mullerian duct aplasia in an XX individual with female phenotype presenting primary amenorrhea at adolescence. Multiple abnormalities may be associated with the MRKH syndrome. Genetic investigations focused on the genes of anti-Mullerian hormone and its receptor, as well as on Wt1, Pax2, Cftr and Hox genes, have been unproductive. Only the Wnt4 gene has been clearly implicated in MRKH syndrome and found to be associated with clinical and/or biological signs of hyperandrogenism in three different works. Beside the multiple malformations that may be associated with MRKH syndrome, such as renal, skeletal, cardiac and auditory defects, MRKH and hyperandrogenism represent a new clinical and genetic disorder.
  • Zhao2009 Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2009 Mar;23(3):309-12, [Clinical application of autologous buccal micro-mucosa graft in vaginal reconstruction], [Article in Chinese], Zhao M, Li Q, Li P, Zhou C, Duan C, Huang X, Chen B, Liu X, Li S., Second Department of Plastic Surgery Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100144, PR China.
OBJECTIVE To investigate the effect of vaginal reconstruction with autologous buccal micro-mucosa graft.
METHODS: From March 2007 and April 2008, 10 patients with absence of vagina were treated, aged 18-31 years (mean 26 years). Nine of them were congenital absence of vagina, and the remaining one was vaginal stenosis after vaginal reconstruction. They all exhibited normal secondary sexual characteristics, normal hormonal levels and 46, XX karyotype. Their abdominal ultrasonography revealed the normal ovaries and tubes but absence of the uterus or small rudimentary horns. However the one with vaginal stenosis had normal uterus. The buccal mucosa graft was minced into 0.5 mm in size and was transplanted to the cavity which was dissected between the bladder and the rectum.
RESULTS: The operation was performed successfully in all cases. The operative time was about 1-2 hours and operative blood loss was 80-100 mL. Postoperative complication occurred in only one case for vaginal bleeding. The patient recovered and the wound healed well after immediate management. The others healed primarily without any complications. All cases were followed up for 4-16 months. The depth of neovagina which was formed was 6-10 cm and the width was about two fingers. The lining was pink-colored and smooth, and was confirmed as nonkeratinizing squamous stratified mucosa by histopathological examination. The donor sites healed uneventfully with no change in mouth opening. The perineal area was not disturbed. Four patients were married and satisfied with their sexual life without pain and bleeding.
CONCLUSION: Vaginal reconstruction with autologous buccal micro-mucosa graft is an easy, minimally invasive and useful method.
  • Idrees2009 J Pediatr Adolesc Gynecol. 2009 Oct;22(5):e148-55. Epub 2009 Jul 17, Squamous papilloma with hyperpigmentation in the skin graft of the neovagina in Rokitansky syndrome: literature review of benign and malignant lesions of the neovagina, Idrees MT, Deligdisch L, Altchek A., Department of Pathology, Mount Sinai Medical Center, New York, New York, USA, PMID: 19616457
BACKGROUND: It is rare for a benign or malignant neoplasm to develop in a neovagina.
CASE: This is the first report of a squamous papilloma with hyperpigmentation which developed in the neovagina 12 years after a McIndoe procedure was done with a split-thickness skin graft from the patient's buttock. The patient had congenital absence of the vagina and uterus (Rokitansky syndrome, Mayer-Rokitansky-Küster-Hauser syndrome, MRKH syndrome). It presented as post-coital blood spotting for 3 months.
CONCLUSION: As a routine, all cases of vaginal construction regardless of the reason for the surgery or the lining of the neovagina should have a continuous annual examination and careful inspection of the entire vagina. Biopsy of any unusual finding should be done. Despite the dark color of the vaginal lesion, bleeding and rapid appearance our patient had a benign tumor. Radiation therapy to the neovagina and prolonged treatment with podophyllin and cauterization should be avoided.
  • Altchek2010 J Pediatr Adolesc Gynecol. 2010 Feb;23(1):e5-8. Epub 2009 Sep 3. Cultured bilayered skin allograft for vaginal construction. Altchek A, Hanflik A, Deligdisch L, Brem H., Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai School of Medicine and Hospital, New York, NY, USA., PMID: 19733098
OBJECTIVE: This is the first report of live human cultured bilayered skin allograft (taken from another person) (LHCBSA) to line a dissected space to create a vagina.
CASE: A 19-year-old with Mayer-Rokitansky-Küster-Hauser syndrome (MRKH syndrome) of vaginal and uterine agenesis had a space dissected and lined with LHCBSA. Although the lining devitalized within 2 weeks, there was a rapid ingrowth of vaginal mucosal cells from the vaginal dimple with an excellent long-term result.
CONCLUSION: This is the first report that LHCBSA is able to stimulate vaginal mucosal cell growth for a neovagina. It is possible that it might stimulate other surface tissue lining to cover adjacent raw areas such as bladder or esophagus.
Copyright © 2010 North American Society for Pediatric and Adolescent Gynecology. All rights reserved.
  • Creatsas2010 Fertil Steril. 2010 Oct;94(5):1848-52. Epub 2009 Nov 25. Creation of a neovagina after Creatsas modification of Williams vaginoplasty for the treatment of 200 patients with Mayer-Rokitansky-Kuster-Hauser syndrome. Creatsas G, Deligeoroglou E, Christopoulos P. Division of Pediatric-Adolescent Gynecology and Reconstructive Surgery, Second Department of Obstetrics and Gynecology, Medical School, University of Athens, Aretaieion Hospital, Athens, Greece. PMID: 19939365
OBJECTIVE: To present and evaluate the results of the Creatsas modification of Williams vaginoplasty for the creation of a neovagina in young women with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome.
DESIGN: Retrospective study.
SETTING: Division of Pediatric-Adolescent Gynecology and Reconstructive Surgery, Second Department of Obstetrics and Gynecology, University of Athens, Aretaieion Hospital, Athens, Greece.
PATIENT(S): Two hundred patients with the MRKH syndrome.
INTERVENTION(S): Clinical examination, pelvic ultrasound, intravenous urography and/or renal ultrasound, laparoscopy, karyotyping, orthopedics and ears, nose, and throat examination, magnetic resonance imaging, and Creatsas modification of Williams vaginoplasty.
MAIN OUTCOME MEASURE(S): Neovaginal functional dimentions, neovaginal axis deviation, and quality of sexual life.
RESULT(S): A functioning vagina of 10-12 cm in depth and 5 cm in width was created in 191 cases (95.5%). A vagina between 7 and 9 cm in depth and 2 and 3 cm in width was created for the remaining nine patients (4.5%). In addition, 94.5% declared themselves to have a satisfactory quality of sexual life, while only 5% of the cases reported an adequate one.
CONCLUSION(S): Creatsas modification of Williams vaginoplasty is a simple, quick, and effective method for the treatment of vaginal agenesis.
Copyright © 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.
  • Morcel2007 Morcel, Karine and Camborieux, Laure and Programme de Recherches sur les Aplasies Mulleriennes (PRAM) and Guerrier, Daniel, Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome, Orphanet Journal of Rare Diseases, V2, 2007, No. 1, pages 13, DOI: 10.1186/1750-1172-2-13, PubMedID: 17359527, ISSN: 1750-1172
The Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is characterized by congenital aplasia of the uterus and the upper part (2/3) of the vagina in women showing normal development of secondary sexual characteristics and a normal 46, XX karyotype. It affects at least 1 out of 4500 women. MRKH may be isolated (type I) but it is more frequently associated with renal, vertebral, and, to a lesser extent, auditory and cardiac defects (MRKH type II or MURCS association). The first sign of MRKH syndrome is a primary amenorrhea in young women presenting otherwise with normal development of secondary sexual characteristics and normal external genitalia, with normal and functional ovaries, and karyotype 46, XX without visible chromosomal anomaly. The phenotypic manifestations of MRKH syndrome overlap with various other syndromes or associations and thus require accurate delineation. For a long time the syndrome has been considered as a sporadic anomaly, but increasing number of familial cases now support the hypothesis of a genetic cause. In familial cases, the syndrome appears to be transmitted as an autosomal dominant trait with incomplete penetrance and variable expressivity. This suggests the involvement of either mutations in a major developmental gene or a limited chromosomal imbalance. However, the etiology of MRKH syndrome still remains unclear. Treatment of vaginal aplasia, which consists in creation of a neovagina, can be offered to allow sexual intercourse. As psychological distress is very important in young women with MRKH, it is essential for the patients and their families to attend counseling before and throughout treatment.
  • Bhargava2008 Saurabh Bhargava, Jacob M. Patterson, Richard D. Inman, Sheila MacNeil, Christopher R. Chapple, Tissue-Engineered Buccal Mucosa Urethroplasty--Clinical Outcomes, European Urology, Volume 53, Issue 6, June 2008, Pages 1263-1271, ISSN 0302-2838, DOI: 10.1016/j.eururo.2008.01.061.
Abstract: Introduction: Whilst buccal mucosa is the most versatile tissue for urethral replacement, the quest continues for an ideal tissue replacement for the urethra when substantial tissue transfer is needed. Previously we described the development of autologous tissue-engineered buccal mucosa (TEBM). Here we report clinical outcomes of the first human series of its use in substitution urethroplasty.
Methodology: Five patients with urethral stricture secondary to lichen sclerosus (LS) awaiting substantial substitution urethroplasty elected to undergo urethroplasty using TEBM, with full ethics committee support. Buccal mucosa biopsies (0.5 cm) were obtained from each patient. Keratinocytes and fibroblasts were isolated and cultured, seeded onto sterilised donor de-epidermised dermis, and maintained at air-liquid interface for 7-10 d to obtain full-thickness grafts. These grafts were used for urethroplasty in a one-stage (n = 2) or a two-stage procedure (n = 3). Follow-up was performed at 2 and 6 wk, at 3, 6, 9, and 12 mo, and every 6 mo thereafter.
Results: Follow-up ranged from 32 to 37 mo (mean, 33.6). The initial graft take was 100%, as assessed by visual inspection. Subsequently, one patient had complete excision of the grafted urethra and one required partial graft excision, for fibrosis and hyperproliferation of tissue, respectively. Three patients have a patent urethra with the TEBM graft in situ, although all three required some form of instrumentation.
Conclusions: Whilst TEBM may in the future offer a clinically useful autologous urethral replacement tissue, in this group of patients with LS urethral strictures, it was not without complications, namely fibrosis and contraction in two of five patients.
Keywords: Balanitis xerotica obliterans; Buccal mucosa; Lichen sclerosus; Oral mucosa; Substitution urethroplasty; Tissue engineering; Urethroplasty

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