1、Dr. Meltzer positions the anesthetized patient in preparation for surgery. Sequential compression stockings are wrapped around the patient� calves and lower thighs; these decrease the risk of blood clots in the legs.
2. The skin has been marked with purple surgical marker. Note the roughly circular area of scrotal skin; this will be harvested for use as a vaginal graft. The small triangular flap at the bottom will be incorporated into the vaginal introitus to avoid a circular scar in this location.
3. The patient� genitals have been washed with antiseptic soap, and sterile drapes have been applied. The device on the left will be used to hold a ring retractor later in the operation to facilitate creation of the vaginal cavity (see frame #11). Note the transparent drape stapled to the skin with surgical staples. It incorporates a latex sheath; this allows the surgeon to insert a finger into the rectum during creation of the vaginal cavity, without contaminating his gloves or the surgical field. As it turns out, Dr. Meltzer will not need to use it during this operation.
4. Surgery begins. Dr. Meltzer first harvests the scrotal skin graft. He uses a yellow-handled electrosurgical device, which both cuts tissue and coagulates blood vessels.
5. Here is what the resulting scrotal skin graft looks like. We�l see it again, looking somewhat different, in frame #9.
6. The testicles are now isolated and removed. Here the right testicle and cord are pulled upward by an assistant as Dr. Meltzer performs the dissection.
7. Next Dr. Meltzer dissects the penile skin free of the underlying erectile tissue. He makes a circumferential cut around the glans, and begins to free up the penile skin. He� holding the glans between the thumb and index finger of his left hand. Two skin hooks held by an assistant keep tension on the penile skin.
接着Dr. Meltzer将阴茎表皮与其下的勃起组织分割。他先围绕着龟头周围切割，然后顺势逐步切割剥离阴茎的表皮。图中Dr. Meltzer用左手的拇指和食指握住龟头，一位助理则以两个皮肤勾来保持阴茎皮肤的张力。
8. Here we see the result when the dissection is complete. Above, an assistant holds the freed tube of penile skin, ready to be turned inside out to line the vagina. Below, the remaining erectile tissue of the penile shaft lies wrapped in gauze to control bleeding.
9. Remember the piece of scrotal skin we saw in frame #5? While Dr. Meltzer has been working, his assistant has scraped it thin and has sewn it into a closed tube, using a large syringe cover as a support. In the next photograph, this whole assembly will be inserted through the inside-out penile skin tube, allowing this graft to be sewn into place.
10. Here the syringe cover carrying the scrotal skin graft has been inserted through the inside-out penile skin tube. The graft is being sewn to the edge of the penile skin. This lengthens the skin tube, which will be used to line the vaginal cavity.
11. It� time to create the vaginal cavity. In this photograph, Dr. Meltzer� left index finger is in the cavity, checking its depth. We can also see two special techniques Dr. Meltzer uses to make this difficult dissection easier. First, he inserts a Lowsley prostatic retractor through the penis, allowing him to manipulate the prostate gland during the dissection. The T-shaped handle of this retractor is visible in Dr. Meltzer� right hand at the top of the frame. Second, he uses a Bookwalter pediatric ring retractor system to keep the vaginal cavity open as the dissection progresses. Two retractors attached to the bottom of the ring maintain downward and lateral pressure within the cavity.
接下来就要製造阴道了。如图，Dr. Meltzer用食指测试开口处的深度。图中显示Dr. Meltzer使用两种特殊技巧来进行这个复杂的切割手术。首先，他将Lowsley前列腺牵引器插入阴茎，以便在进行切割时方便操控前列腺，图片上方还可以在Dr. Meltzer的右手中看到牵引器的T形手把。其次，Dr. Meltzer用了Bookwalter小儿科环形牵引器系统来保持阴道张开，以利整个切割手术进行，环底附着的两个牵引器则维持了阴道向下和侧面的压力。
12. With the vaginal cavity complete, Dr. Meltzer cuts into the corpus spongiosum at the base of the penis, opening the urethra. He inserts a Foley catheter through the urethral opening into the bladder. The surrounding tissue will be trimmed back further later in the operation to create the new urethral meatus, or opening.
13. Dr. Meltzer now begins to strip the erectile tissue from the penis. Eventually this will leave only the glans and a thin pedicle containing the dorsal blood vessels and nerves. Dr. Meltzer cuts into the erectile tissue from both the left and right sides to begin this process.
14. Soon only a ribbon-like pedicle connects the glans to the rest of the body. Carefully preserved blood vessels and nerves within the pedicle keep the glans tissue viable and sensate.
15. Dr. Meltzer begins to shape the glans tissue to form the clitoris. The bottom one-half of the glans has been cut away. The edges of the cut surface are sewn together, producing a clitoris of the desired size.
16. In this photograph, the skin of the lower abdomen has been freed from the underlying tissue, up to the level of the navel. A retractor pulls the skin upward. Freeing this skin will allow the attached penile skin, which is hidden by the retractor, to be pulled down far enough to enter the vaginal cavity. The pedicle containing the nerves and blood supply of the clitoris has been folded over on itself, and the clitoris has been sewn into its final position.
17. Now it� time to place the skin graft into the vaginal cavity. Dr. Meltzer inserts a large curved retractor into the tube of penile and scrotal skin to help guide it smoothly into the cavity. His right hand holds the retractor; his left is at the opening of the vaginal cavity.
现在可以将植皮放进阴道了。Dr. Meltzer将一支弯嘴牵引器插入阴茎阴囊合成的植皮管道，引导这个管道顺利的进入体腔。Dr. Meltzer的右手握住牵引器，左手则在阴道的开口处。
18. After some trimming, Dr. Meltzer sews the vaginal skin graft to the skin of the perineum, anchoring it in place.
19. Dr. Meltzer makes a small incision in the skin of the new vulva to accommodate the clitoris, which we see here sewn into position. A second lower incision is also visible; this will be the new urethral opening. A weighted retractor is in the vaginal cavity.
20. Now the urethral tissue has been trimmed, and has been brought through the lower incision in the vulva, creating the new urethral meatus. A Foley catheter in the urethra marks this opening, which is very close to the opening of the vagina. We can see that there is still a lot of excess scrotal skin, which must be trimmed to create the labia majora.
21. In this photograph, Dr. Meltzer has trimmed the skin of the labium on the right (patient� left), and is beginning to close the incision with sutures. A drain tube extends from the upper end of the labium; this will drain any accumulated blood or fluid during the first few days after surgery.
22. With both labia trimmed to shape and sutured, Dr. Meltzer inserts a speculum into the vagina in preparation for inserting the vaginal packing.
23. In this photograph the gauze packing has been placed in the vagina; its white color marks the vaginal opening. Dr. Meltzer now begins placing the temporary stitches that will hold the labia together for a few days. These temporary sutures will compress the labia, reducing bleeding and swelling.
24. The labia have now been sutured together almost completely. The drains and the Foley catheter come out at the top. Except for the applying the final dressings, the operation is complete.
25. This photograph, from a different patient, shows what the result will look like when it has healed. A second-stage labiaplasty will be necessary to hood the clitoris and create the labia minora.