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Introduction: Phalloplasty is a complex surgical task and remains a significant challenge in plastic surgery. To date, there are various techniques; however, complication rates are still not satisfactory. Here, we present our surgical approach of a modified tube-in-tube concept combining a radial forearm free flap and an anterolateral thigh flap and assess its outcome in a series of female-to-male transsexuals.

Patients and methods: In this report, 21 female-to-male transsexual patients were included. The first surgical step includes colpectomy and elongation of the fixed part of the urethra with a full-thickness skin graft. Subsequently, a radial forearm free flap was adapted to build the inner tube which represents the neourethra. For the last step, a free anterolateral thigh flap is utilized as the outer tube of the neophallus. All patients were evaluated regarding aesthetic and functional outcomes as well as postoperative complications and revision surgeries.

Results: Our results showed a 100% flap survival rate with a mean follow-up of 4.4 years (range, 2.7-6). Three radial forearm free flaps and one free anterolateral thigh flap presented with partial flap necrosis. Generally, complications occurred in 11 patients (52.4%). The most common complications were related to urethral reconstruction including fistula formation (n = 8) and stenosis (n = 5). All except one patient obtained the ability to void while standing.

A large experience has been obtained at our centre with more than 350female-to-male transsexuals who underwent a penile reconstruction. In thispaper, our experience in phalloplasty using the free radial forearm free flap(RFF) or the pedicled anterolateral thigh flap (ALTF) is described for patientswith severe penile inadequacy.

This flap is harvestedfrom the forearm and shaped to a phallus using a tube-in-a-tube technique whilebeing attached to the forearm by its vascular pedicle. A small skin flap andskin graft are used to create a corona and a sulcus to imitate a circumcised glansof the penis. The free flap is then transferred to the pubic area and after performingthe urethral anastomosis, the radial artery is microsurgically connectedend-to-side to the common femoral artery. The venous anastomosis is performedunder microscopic magnification between the cephalic vein and the greatersaphenous vein. One forearm nerve (N.cutaneus antebraci) is connected to theilioinguinal nerve for protective sensation and the other nerve is anastomosedto the dorsal penile nerve for erogenous sensation.

This flap is a pedicledperforator flap supplied by the descending branch of lateral femoral circumflexartery. The perforator vessels are identified using Doppler-ultrasound justprior to incision. The lateral femoral cutaneous nerve is transsected afterharvesting the flap. The flap is tunneled underneath the adductor muscles andthen transferred to the pubic area. At this moment, the flap is shaped into aphallus using the tube-in-tube technique. Once at the pubic area, the urethralanastomosis is finished. Any tension on the pedicle must be avoided. The nerveis reattached to its stump using a subcutaneous tunnel above the adductormuscles.

In this series, the RFF was the method of choice. No complicationsconcerning flap survival or at the donor site were reported. Of the sevenpatients treated with RFF, the aesthetic appearance was good in 6 patients andmoderate in 1 patient. Other seriesusing the RFF in penile insufficiency also report encouraging results with agood aesthetic appearance and low donor site morbidity. The results ofphalloplasty using radial forearm free flap in penile insufficiency areencouraging, the aesthetic appearance is good and donor morbidity is low [6, 7]. Erotic sensation was reported by allpatients treated with RFF. Althougd subjective (a questionnaire was used), thisfinding is consistent with the work of Selvaggi et al. [8]. Coaptation of oneof the cutaneous nerves of the flap with a remnant of the dorsal penile nerveseems to be essential in obtaining this result.

Nevertheless, other types of free flaps have been described: Djordjevicet al. [9] reported the musculocutaneous latissimus dorsi free flap, Sengezeret al. [10] suggested the osteocutaneous free-fibula flap, and N. Felici and A. Felici[11] described the free anterolateral thigh flap. They all report satisfactoryresults. The type of free flap that is used mostly depends on the personalpreference and the experience of the plastic surgeon that is involved inphalloplasty.

Due to the devastating impact on the psychological and sexual function,penile reconstruction of severe penile inadequacy is needed. Today, penilereconstruction using phalloplasty is available. A free flap, such as the radialforearm free flap, is the method of choice because of good aesthetic results,low donor site morbidity, and excellent erogenous sensitivity. In case a freeflap is contraindicated, a pedicled flap, such as the anterolateral thigh flap,should be used. This flap has comparable aesthetic results, but sensitivity isa major concern in this flap.

The photo above purports to show (Lutheran) Church of Sweden clergy demonstrating yesterday in Stockholm to "break the conspiracy of silence regarding homosexuals, bisexuals, and transsexuals." Few of us, perhaps, would have noticed a great deal of silence on the issue, but I suppose these ministers are specially trained to listen for it. But my interest was tweaked by a side issue: the marchers' use of the roman collar. In standard progressivist polemic, the roman collar is deplored as a token of clericalism, and more particularly of the hierarchical subordination typified by the Church of Rome. We might expect that progressives, in keeping with their anti-hierarchical convictions, would never let themselves appear in the roman collar, either dressing indistinguishably from the laity or creating an alternative garb more emblematic of humility. Yet the fact is that attempts at replacement insignia have flopped; no badge expresses the notion "clergy" as unequivocally as the roman collar. This means that -- on those infrequent occasions when progressivists want to be publicly identifiable as clergy -- on goes the collar, out go the principles. It's not without an amusing side. Those instances on which the forward-thinking brethren summon the bad old hierarchical caste system to their aid do not redound to their credit. Attorneys for priest-defendants regularly stuff them into the too-snug clerics fished out from the depths of the rectory closet, hoping the jury will atavistically respond to the uniform. Here's an example from a churchman indicted for advanced ideas about youth ministry: Fr Joseph Jordan was a modern priest, always dressed in baseball cap, tracksuit and trainers. One mother remarked that the only time she had seen him in clerical garb was in the dock at Cardiff Crown Court. In addition to arraignment fashions, the roman collar also comes in handy when television or news cameras are at hand, and it's politically more expedient for, say, Professor Richard McBrien to weigh-in as Father Richard McBrien. Dressed in a jacket and tie, a refractory Catholic academic comes across on the tube as just another refractory Catholic academic, his Holy Orders notwithstanding. (For analogous reasons, when military officers go on television to oppose some aspect of administration policy, the producers make sure they're in uniform.) And then, finally, there is the public street demonstration, as exemplified in the photo from Stockholm. The marching ministers even put aside their pastel clergy shirts in favor of deadpan Catholic black, lest inattentive spectators mistake them for random amateur cross-dressers. There's a "me too" dimension to their use of the roman collar: "You should take us seriously, because the collar is an emblem of clergyhood and clergyhood an emblem of ecclesial authority and ecclesial authority an emblem of moral seriousness -- not that we are morally serious in fact, but we have fierce political passions for which some kind of public legitimacy is needed." In a paradoxical way, progressivists' infrequent tactical resort to clerical garb is more "clericalist" than conservatives' day-in day-out use of the same. After all, the conservative can say, "Hey look. I'm a priest around the clock, and I'm just doing what I'm told, just keeping to Canon 284, so I take the multiple headaches along with the occasional advantage that comes with the collar." But the trendy clergyman, who dresses as a layman 99 percent of the time and puts on clerics only as a signal to strangers and only for some tactical advantage, is trading precisely on the moral prestige that society imputes to the clerical caste as a whole. He's saying in effect: "Pay greater attention to my words, because -- when all is said and done -- it's the Church that's speaking." To pull this stunt is to borrow the moral authority that belongs to an institution so as to exploit it for personal gain, and of such is the kingdom of clericalism. Photo: Le Figaro (AFP/Nackstrand) 041b061a72


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