1996 | Dieffenbach-Medaille
Dieffenbach-Medaille Prof. Charles Horton
Die Dieffenbach-Medaille 1996 wurde Prof. Charles Horton (im Foto links) auf der VDPC-Jahrestagung in Köln am 9. Oktober 1996 von VDPC-Präsident Prof. Dr. Rolf Rüdiger Olbrisch überreicht.
Johann Friedrich Dieffenbach-Vorlesung 1996
Genital Plastic Surgery
Charles E. Horton, M.D., FA.C.S., FR.C.S. (G) (Hon.)- 9. Oktober 1996 Köln-
lt is a great honor for me to address the German Association of Plastic Surgeons and to recognize Johann Friedrich Dieffenbach, one of the great Ieaders in the world of plastic surgery and to give the Dieffenbach Lecture. I share with all our plastic surgeons our great respect and admiration for your numerous early German pioneers and giants of plastic surgery. This admiration and respect carries on to your present association, its members and the excellent exploring, defining and refining examples of modern plastic surgery that you represent. I thank all of you for inviting me to discuss the subject of genitourinary reconstruction.
Nowhere in the body is there more emotional or psychological stress present than in a patient who feels he or she is not genitally normal and ultimately cannot participate in normal sexual relationships with a potential mate. ln all religions the concept of male and female bonding through marriage is encouraged and promoted. As children go through puberty with maturation of their genital apparatus they naturally grow to anticipate sharing normal Iove and respect in their sexual activities. When they cannot, because of infirmity, a sense of self-depreciation and depression may ensue. Many suffer in silence. Most find it difficult to discuss their problems with family, friends or even physicians. We are conditioned to be embarrassed when discussing sexual problems, particularly with parents, and even with physicians.
Genital abnormalities can be discussed under four categories (Four „C“)
1. Cancer and degenerative processes
2. Catastrophic or traumatic defects
3. Congenital defects
4. Cosmetic imperfections
Cancer and Degenerative Processes
Cancer of the penis, scrotum, vagina and vulva fortunately do not occur often but are sources of terror for the patient and spouse who suddenly face radically changed lives. With microsurgery, and newer flap sources (gracilis, rectus, tensor, fascialatae, posterior thigh, radial forearm, etc.,) almost any major genital defect can be reconstructed satisfactorily. The cure of the cancer must remain paramount, but the rehabilitation of the patient must also be considered. lf the total penis is lost due to cancer or trauma, a sensory aesthetic penis can be built. Short penile shafts from partial amputation can be lengthened with pubic defatting, release of skin tethering and partial diversion of the suspensory Iigament combined with full thickness skin grafts. lf the vagina has been surgically removed, a new functioning vagina can usually be reconstructed at the time of extirpation or later. Rare cancers such as Bowen’s Disease, Padget’s Disease, Epithelioid Sarcoma, Erythroplasia of Quarat and Melanoma must be considered in every problem case. Adequate treatment with standard plastic surgery techniques is available.
Degenerative processes such as Peyronie’s disease and impotence occur frequently in our practice. The penile prosthesis is an accepted, well tolerated remedy when all else fails in the impotent patient. When Peyronie’s Disease causes severe curvature and intercourse is impossible, surgery with dermal graft repair of the diseased tunica has been successful in a high percentage of cases and is our treatment of choice. Severe skin damage from radiation or chronic infection (hidradenitis) and lymphedema of the scrotum and penis should be treated with excision and grafting. While we prefer full thickness grafts for most cases in the repair of skin defects of the genital area, in radiation damage and in lymphedema we recommend split thickness grafts. These grafts are particularly valuable in radiated areas. Full thickness grafts used to resurface after lymphedematous penile and scrotal tissue removal contains dermal elements which later will become secondarily lymphedematous, and should not be used to reconstruct the detect.
Catastrophic and Traumatic Defects
Thermal and electrical burns are common injuries of the genital area which occasionally cause massive and severe tissue destruction. lf the damage is confined to skin loss only, routine skin grafting is necessary. lf the damage is deeper, flaps and graft reconstruction can be applied. Cautery burns at circumcision results in frequent penile injury causing total or partial loss of the phallus. Animal bites, farm accidents, automobile accidents, electrical burns, self mutilation, malicious amputations and even torture in modern underdeveloped countries can also be the cause of sub-total or total penile loss. These must be managed according to the amount of penile loss. lf the penile shaft is retracted beneath scarred skin, a simple release of scarred skin, plus pubic defatting, and release of the suspensory Iigament may allow enough of the shaft of the penis to extrude so that when it is grafted with a full thickness graft, a functional penis can be obtained. lf total loss of the phallus occurs in a very young patient, then a decision as to whether the infant is to be raised as a female (with later reconstruction of the vagina) must be made. With new advances in phallic reconstruction we believe this technique has emerged as a viable consideration in the treatment of these cases. lf the traumatic loss is later in life, there is no question but that reconstruction of the phallus is indicated. We can now make a forearm flap penis with coaptation of the pudendal nerve to the sensory nerve of the arm flap, so that the new penis has erogenous sensation and the patient can achieve organism.
Hypospadias surgery has changed in my lifetime. No more multiple stages, no sub-glandular urethral meatus, no protuberant pouches, no more obvious, abnormal scarring, for the public is aware of newer and better techniques to prevent these problems, and expects their surgeon to provide proper care. Epispadias, while more difficult to treat, is a correctable problem. Persistent exstrophy defects with incontinence and an abnormal escutcheon are not now acceptable. Using avail able current surgical techniques for both male and female, the usual former poor results can be avoided and/or corrected. Vaginal agenesis has become an easily treated anomaly. Severe congenital penile curvatures are usually adequately treated in one operation, yet many teen aged patients with this problem are seen after becoming a recluse in their room and refusing to mix both with parents and with society. The individuals fear they are „inferior“, and are an „object of scorn“ that will be maimed and marked for life. Their parents frequently do not know of the problem, and suspect their child is taking drugs or is psychologically abnormal. Simple surgery can change this life. These patients are simply confused and do not have adequate information that their problem can be repaired.
Absence of the penis or microphallus is not common but still presents a challenge in the decision as to whether to change the anatomical sex of the newborn (otherwise a normal male) to a female. Such early sex change surgery is usually successful but now plastic surgeons have perfected such good phallic reconstructive techniques that we must reconsider and challenge this concept by carefully examining both potentials. More rare conditions such as duplicate urethras, duplicate vaginas, intersex, diaphallus and scrotal malpositon problems usually can be salvaged with present techniques.
Even plastic surgeons may be accused of bias when we eagerly accept breast augmentation in the female (which is an improvement in a secondary sexual object) and refuse to treat cosmetic defects of the genital area because of fear that patients may be psychologically unstable. Many reasonable patients seek consultation for genital scars, discolorations, cosmetic or functional curvatures, Iack of prepuce, absence of an umbillicus, smaller than desired penis, enlarged Iabia, the meatus displaced from the tip of the glans, an abnormally protruding pubic mass, or even Iack of or mal-distribution of pubic hair. We recognize in plastic surgery that we should be wary of individuals with unreasonable expectations, however, plastic surgery should try to meet the challenge of these requests when they come form reasonable people. Many of these problems can be treated and improved with standard plastic surgery techniques. Methods to reconstruct the prepuce or enlarge the penis are not now satisfactory in all cases and we must develop new techniques to meet the demand for these operations. We must seek to find new improvements in surgical techniques which are not now presently available. Transsexual surgery is increasingly in demand and presently we have the ability to achieve spectacular functional and cosmetic results for these troubled individuals.
Because surgery concerned with sexual performance is so basic in every persons life, there are, of course, individuals who over react to their perceived problem. They may see every little defect as major and can never be satisfied. We often hear these patients say, „when I was a child my parents robbed me of my prepuce without my consent“, (by circumcision) and „I want- I must have it built back to be whole“. They may want small insignificant scars revised. They may want a normal sized penis made Ionger and increased in girth (dermal fat grafts and division of suspensory Iigament). When we accept a normal sized breast as suitable for enlarging, are we discrimination against the penis if we refuse to operate to make it aesthetically better? There is no question that certain individuals persistently hold and examine their penis trying to demonstrate deformity that is barely visible. lt is imperative that plastic surgeons act with care and diligence to get psychological help for these individuals. Oftentimes the patient who is told that their perception of the problem is in error will be so emotional that they will display unreasonable despair and sorrow in the office, frequently breaking into frank sobs and crying.
We insist that all our unusual problem cases see our sex therapist (M.D.) who has worked in a kind and caring manner for twenty years with our troubled cases. Not only can he identify the potential psychotic case and keep us from error, but he sees our patients postoperatively if reinforcement therapy is needed. Oftentimes husbands and wives see him together and solve their problems with frank discussions. With the threat of legal harassment ever present, we feel the separate consultation by our sex therapist (in which he also states in writing that the patient understands the surgery, the complications and the potential benefits) is of great benefit. Years ago, one of the pioneer plastic surgeons of a major university in the United States was shot and killed by an unhappy hypospadias patient. I believe there is an increased potential for great misunderstanding to occur in these cases and we welcome the cooperation and assistance of these consultations.
I cannot detail all of the problems encountered in genital reconstructive surgery because of space limitations. You can recognize that a single topic mentioned above would deserve and individual paper – and that books are published on genital reconstruction. I would emphasize one last point, and that is the plastic surgeon should definitely be involved in work in this area and should not be excluded by other specialists. We have much to contribute. We are innovative and creative, and bring to the operating table techniques not familiar to urologists, paediatric urologists, gynaecologists and paediatric surgeons. These specialists have, because of their anatomical territory, become quite expert in routine reconstructive cases. When problems occur, when flaps, grafts, z-plastic, microsurgery, musculocutaneous flaps and other complex reconstructive manoeuvres are needed, the plastic surgeon is called. lf the plastic surgeon is not familiar with the healing potential, the blood supply, the reaction of tissues (because he has done little work in this anatomical area) then the potential of assistance is diminished. We need to work constantly in this area, even in simple cases, to be able to contribute. I believe we should find a urological or surgical colleague who is a compatible co-worker and arrange joint surgeries to take the contribution of plastic surgery and other cooperating specialists to the operating table together. ln my opinion, this will decrease the inevitable unusual complications of routine cases, and will allow maximum contributions for complex cases.
Thank you for inviting me to honor Doctor Dieffenbach. I know that had he the advantages of anaesthesia, blood transfusions, microsurgery, antibiotics, etc. that his name would be connected to even more innovative and pioneering in the genital reconstructive field. We respect him as a surgical giant, and I am proud to have been asked to honor him.
Charles E. Horton,
M.D., F.A.C.S., F.R.C.S., (G) (Hon.)
Professor of Plastic Surgery Eastern Virginia Medical School Norfolk, Virginia
Clinical Professor of Plastic Surgery
Medical College of Virginia
Quelle: Mitteilungen VDPC Nummer 6, 4. Jahrgang September 1997