变性手术（男变女）

　　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.
　　Dr. Meltzer将麻醉了的病人安置好，準备手术。病人的大腿下部到小腿都包裹了一连串的压力袜，以便避免血液在腿部凝结成块。


　　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.
　　要切除的阴囊表皮已经用外科紫色笔标记出来。请注意，环绕阴囊的那片约略圆形区域的皮肤稍后将作为阴道植皮之用。底部那一小块叁角形的盖皮未来将会併入阴部的开口，以避免在这个部位形成圆形的疤痕。


　　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.
　　先用消毒皂清洗病人的生殖器，然后盖上消毒布帷。图左的这个装置是用来稳固环状牵引器，以便稍后用来帮助製造阴道的甬道(见图11)。请注意图中固定在皮肤上的外科透明布帷，布帷上设有乳胶套，外科医生在製造阴道时可以透过这个乳胶套将手指插入直肠以维持稳定，而不至于被肛门的污物污染手套或是手术区域。后来发现，Dr. Meltzer在这次的手术中并不需要用到那个步骤。


　　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.
　　手术开始。Dr. Meltzer先切除阴囊表皮，留作稍后阴道植皮之用。这裡使用的是一把黄柄的电动外科器具，在切除组织的同时还可以封凝血管。


　　5. Here is what the resulting scrotal skin graft looks like. We?l see it again, looking somewhat different, in frame #9.
　　这就是切下的阴囊表皮。后来再看到它时，样子会有些不同(见图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.
　　阴囊皮去除后，睪丸就可以被独立出来，然后移除。图中当Dr. Meltzer在施行切除手术之时，他的助理正在将右睪丸以及韧带部份往上拉。


　　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.
　　这是阴茎表皮剥离后的结果。图中一位助理拉住已经被剥离的阴茎表皮，预备外翻，以作为阴道的内衬。在图的下方，阴茎残余的勃起组织也已裹上了纱布以控制流血。


　　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.
　　还记得我们在图5看到的那块阴囊表皮?Dr. Meltzer进行手术的同时，他的助理便将这块阴囊表皮刮薄，以一支大型皮下注射器套作为支撑，将切下的阴囊表皮缝成一端封闭的管状。在下一张图中，这整个成品都会被放进由那个外翻的阴茎表皮缝成的管道内，以便把这个管状植皮缝到适当的位置。


　　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.
　　在这裡，套着阴囊植皮的皮下注射器套已经放进了阴茎表皮做成的管道内，植皮正在被缝进阴茎表皮管道的边缘。这样一来就拉长了阴茎表皮管道，稍后可以用来当作阴道的内衬。


　　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.
　　当阴道的甬道做好后，Dr. Meltzer切开阴茎根部的海绵组织，以便打开尿道，他将一根Foley导管穿进尿道口，放进膀胱内。在接下来手术创造新的尿道和尿道口时，这些周围组织都要重新修整过。


　　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.
　　Dr. Meltzer现在开始从左右两侧切入，将阴茎周围的勃起组织剥除。最后将只留下龟头以及一片薄薄的、背侧有血管和神经的肉茎。


　　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.
　　现在龟头只靠着一条像缎带一般的肉茎来和身体连结，但是被小心保存在这条肉茎内的血管和神经将继续活络龟头的组织和感觉。


　　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.
　　Dr. Meltzer开始将龟头组织塑成阴蒂，他先将龟头的下半部切除，然后将切口的边缘缝合，製造了一个大小适当的阴蒂，相连的肉茎则将提供阴蒂所需的神经和血液。


　　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.
　　如图，下腹皮肤已经和其下的组织分开，以一个牵引器往上拉到肚脐的高度。将下腹皮肤拉开是为了让(图中被牵引器挡住的)阴茎皮可以被向下拉到足以进入阴道的程度。另一方面，连接阴蒂的那条肉茎也已经被反摺，好把阴蒂缝到应有的位置上。


　　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.
　　经过一些修整，Dr. Meltzer将阴道植皮缝进会阴的皮肤内，固定好。


　　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.
　　Dr. Meltzer在新阴户的皮肤上开一道口子，阴蒂就放在这裡。我们在这张图片中可以看到缝好后的样子。第二个切口较低，也可以在这裡看到，这是新的尿道口。阴道内有一个加了重量的牵引器。


　　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.
　　现在尿道的组织已经修整好，并且从会阴上较低的那个开口拉出来，开闢成一个新的泌尿管道。尿道上的Foley导管就显示了尿道的开口，位置非常接近阴道的开口处。那裡仍然有很多剩余的阴囊皮肤必须被修整，以创造大阴唇。


　　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.
　　图中Dr. Meltzer已经修整好了右边阴唇的皮肤(也就是病患的左边)，开始缝合切口。从阴唇上端延伸下来一条排除液体的管子，这条管子在术后的几天内都会排出这个区域累积的淤血或体液。


　　22. With both labia trimmed to shape and sutured, Dr. Meltzer inserts a speculum into the vagina in preparation for inserting the vaginal packing.
　　在两片阴唇都修整出形状而且也缝好之后，Dr. Meltzer插入一个扩张器到阴道内做为阴道塑形的準备。


　　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.
　　这张照片中，阴道填入了纱布，图中露出的一点点白纱布就标示了阴道的开口。Dr. Meltzer现在开始暂时缝合阴唇，这种暂时的缝合可以施压阴唇，以减少流血和肿胀，数天后再拆除。


　　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.
　　现在阴唇已经几乎完全的缝在一起了，排除多余淤血体液的管子和Foley导管从顶端冒出来。除了最后的包扎之外，整个手术已经完成了。


　　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.
　　这张照片是另一个病人的，它显示了手术癒后的样子。第二阶段的阴唇整型手术将盖住阴蒂并创造小阴唇。


　　26. 以下几张照片是第二阶段的阴唇整型手术后的效果。


此外，重建阴道时还可以选择用乙状结肠作为材料，效果也很好。手术步骤如下：
1、截取一段乙状结肠，注意要带血运。

2、用肠道吻合器将乙状结肠两断端吻合，恢复肠道连续性。


3、将切取的乙状结肠段的一端封闭，另一端自尿道口后方另戳口引出，阴道重建即可完成。