Author Topic: Looking at peritoneal vaginoplasty with Dr. Gallagher  (Read 13391 times)

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Offline josie76

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Re: Looking at peritoneal vaginoplasty with Dr. Gallagher
« Reply #180 on: September 15, 2020, 08:52:33 pm »
Assuming UI continues, that seems to be an option, the other two surgeons I'm aware of performing PPTV in the US are Bluebond-Langer in NYC and Wittenberg in SF. If you want details on my procedure with the latter (revision), pm me for a link.

I remain concerned about surgeons who enter into this work without adequate training. A group of concerned trans folk wrote an open letter to WPATH about this, seeking standards for training. For my part, I rejected the only local surgeon performing GCS for my primary vaginoplasty precisely for this reason, his training had consisted of observing only 3 procedures.

Now, surely, everyone starts somewhere, especially those who develop new techniques, that's not the same to me as beginning in a new specialty with minimal practice, I would be even moreso with respect to anyone undertaking something as complex as pptv without adequate preparation.

I would agree that being cautious about "new" doctors getting into doing trans surgeries.

About PPV surgery:
Dr. Koch commented that it was really a simple procedure from his part of working with the peritoneum. On my first office visit with him he had commented that he works inside that part of the body every single week. In fact the next day he had 3 prostate removals scheduled. He uses the robot to go through the peritoneum to get to and remove the prostate. His comment was that any urologist should have no problem doing that part. Still I would think that making sure the urologist is an experienced surgeon.

As for Dr. Roth doing the plastic part, seems he was in with Dr. Gallagher doing a number of those before she left IU Health University Hospital.

If anyone knows a good way to reach this team, can you please let me know?

I think you might want to try reaching out to the urology department at the IU Health University Hospital. There are several hospitals in the university system in Indianapolis. Search for Dr. Roth or Dr. Koch's office in urology there.
04/26/2018 bi-lateral orchiectomy
09/11/2019 PPV at IU Health (DaVinci robot laparoscopic Davydov with modified Chonburi Flap) w/ Dr. Gallagher, Dr. Koch, Dr. Roth assisting urology
03/02/2020 revision labiaplasty at IU Health w/ Dr. Gallagher

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I for one want to live now, not just exist!

Offline Nozomi

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Re: Looking at peritoneal vaginoplasty with Dr. Gallagher
« Reply #181 on: September 15, 2020, 11:52:30 pm »
Thanks Danielle, and yes it has gone very well for me. :)
I am glad that it gone very well for you.

My questions are indicated as bold underlined:

Last year I was 61 years old and I have booked a time for my SRS at another hospital this March. After that last December I found this forum and I emailed Emma (Coordinator of Dr. Gallagher at that time), but I could not get her reply. As I thought that this March was the last chance to get long vacation for SRS, I had SRS-1 Vaginoplasty without vaginal depth in Thailand by Dr. Kamol in March 2020 in order to avoid dilation.

But for younger Japanese MTF, I am very interested in the breakthrough PPV method that you developed with Dr. Gallagher and Dr. Koch, It will change the future of our MTF. I respect you profoundly.

Could you answer my questions?
1.   In your reply #124 in this forum at 6 weeks after PPV, “I can now work with the largest size dilator. My depth is consistent at the last for on the dilator. I do not need to add any lube anymore.” And in your reply #163 (at 6 months after PPV, “For those who want to know depth is about 7inches still. There is still more than enough moisture secretions. It seems the deeper parts may not have epthilized yet."
How about now after a year? Is it same as your reply #163 in this forum at 6 months?
Only if it's different, could you answer: How many inches? Enough moisture secretions? No lube required?

2.   Are the dilation frequency and the duration similar to the general ones below?
Only if it's very different, could you answer how often dilation is needed and how many months it is necessary?
Months Since Surgery   Diameter of Dilator     Frequency
0-3                           1-1/8"                       3X per day
3-6                           1-1/4"                       Once daily
6-9                           1-3/8"                       Every other day
9-12                         1-1/2"                       1-2x per week

3.   Dr. Wittenberg indicates in the video of “Dilating 101 part 2” in MoZaic Care of Dr. Wittenberg
(Though I just registered two weeks ago so I can't show each link directly, Could you search “mozaiccare video” in Google -> Videos | mosaic -> Dilating 101 part 2 (video)).
Is your dilation similar to it?

In your reply #148 in this forum, as for the paper of Dr. Gallagher, “it will likely be late this year or early next.”
In your reply #32, “One of the issues Dr. Gallagher had was several urologists who said it wasn't possible to do and less likely with a narrow masculine pelvis…. I gave him all of my research links and discussed it with him.”
So you developed your PPV method with them. I ask you.

4.   In your reply #15, “What we are talking about is a laproscopic Davydov Method vaginoplasty with full exterior reconstruction. This is what has not been done before last year in India. I have found cases published where a PAIS girls had it done where they had "ambiguous genitalia" so a reconstruction but with less than functional male genitals to start with.”
Could you indicate the differences between your PPV method and Dr. Mhatre’s method
in the Journal articles of “New laparoscopic peritoneal pull-through vaginoplasty technique” and
the YouTube of “PriyaMED presents... Sugar's PPV GRS SRS GCS Vaginoplasty”?

5.   Could you list the Journal articles and videos that are absolutely essential to add to Dr. Mhatre’s method?
For your convenience, could you select reference alphabets in your following list?
If there are other absolutely essential articles and videos, could you indicate them?

Video Resouces: (I just registered two weeks ago so the links were removed,)
A)   Badran, Osama. MD, Laparoscopic Neovagina Creation – with audio.
B)   Chittawar, Priya Bhave. Laparoscopic Vaginoplasty: Davydov's procedure.
Journal Articles:
C)   Marton, Ingrid., Habek, Dubravko., UjeviÄ, Boris. Laparoscopic Davydov procedure: 4 cases of neovaginoplasty. ISGE 25th Annual Congress & 4th Croatian Congress. 2016, May 25-28.
D)   Bianchi, Stefano., Berlanda, Nicola., Brunetto, Federica., Bulfoni, Alessandro., Caroggio, Celcilla., Fedele, Luigi. Creation of a Neovagina by Laparoscopic Modified Davydov Vaginoplasty in Patients with Partial Androgen Insensitivity Syndrome. The Journal of Minimally Invasive Gynecology. 2017, Nov-Dec. Vol 24, Issue 7, pages 1211-1217.
E)   Fedele, L., Frontino, G., Restelli, E., Ciappina, N., Motta, F., Bianchi, S. . Creation of a neovagina by Davydov's laparoscopic modified technique in patients with Rokitansky syndrome. American Journal of Obstetrics & Gynecology, Volume 202, Issue 1, 33.e1-33.e6.
F)   Giannesi, A., Marchiole, P., Benchaib, M., Chevret-Measson, M., Mathevet, P., Dargent, D. Sexuality after laparoscopic Davydov in patients affected by congenital complete vaginal agenesis associated with uterine agenesis or hypoplasia.  Human Reproduction, Volume 20, Issue 10, October 2005, Pages 2954–2957,
G)   Jalalizadeh, Mehrsa, MD; Shobeiri, S. Abbas, MD, MBA. Davydov Procedure for Augmenting Vaginal Length in a Postsurgical Male-to-Female Transgender Patient. Female Pelvic Medicine & Reconstructive Surgery: July/August 2018 - Volume 24 - Issue 4 - p e9–e11.
H)   Khadka, R.R., Islam, S., Rahman, S., Ali, Y., Salam, M.A., Hossain, M., Hasan, S., Vaginoplasty in vaginal agenesis associated with MRKH syndrome with tabularized peritoneal pull-through. A Journal of Bangabandhe Sheikh Mujib Medical University, Dhaka, Bangladesh. 2017, issue 10, pages 35-37. doi: 10.3329/bsmmuj.v10i1.31071
I)   Slater, Michael W., Vinaja, Xochitl., Islam, Aly., Loukas, Marios., Terrell, Mark., Schober, Justine. Neovaginal Construction with Pelvic Peritoneum: Reviewing an Old Approach for a New Application. Clinical Anatomy. 2018. issue 31. pages 175–180.
J)   Takahashi, K., Nakamura, E., Suzuki, S., Shinoda, M., Nishijima, Y., Ohnuki, Y., Kondo, A., Shiina, T., Suzuki, T., Izumi, S., Laparoscopic Davydov Procedure for the Creation of a Neovagina in Patients with Mayer-Rokitansky-Kuster-Hauser Syndrome: Analysis of 7 Cases. Tokai Journal of Experimental and Clinical Medicine. 2016 Jun 20;41(2):81-7.

Best regards,
Nozomi


Offline Kara Lee

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Re: Looking at peritoneal vaginoplasty with Dr. Gallagher
« Reply #182 on: September 16, 2020, 12:51:29 pm »
In addition to working alongside Dr Gallagher, Dr Roth also had fellowships in transgender surgeries at Ghent, University in Belgium as well as the Belgrade Center for Genital Reconstructive Surgery in Belgrade, Serbia.

I'm having a followup with him in a week and I'll ask him if they are ready for new patients and, if so, how to contact them.

Offline josie76

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Re: Looking at peritoneal vaginoplasty with Dr. Gallagher
« Reply #183 on: September 16, 2020, 08:32:24 pm »
Could you answer my questions?
Best regards,
Nozomi

Hi Nozomi,

I will do my best to answer your questions.

1-2) no lubricant is needed for dialation. However due to complicated familial issues this spring I did not dialate as I should have. At 6 months I would say about 50-70% of the depth of the peritoneal lining was epthilized. Now I would say it is complete as no blood comes from that area after dialating any longer. With missing dialating sometimes as long as between 2 and 3 weeks I did loose some depth. Essentially that deepest portion had the time between dialating to heal together. The epthilized portion will not do that but what part is not yet epthilized can heal together quite quickly. Now as measured with a dialator I am about 10cm which still leaves me well within the average depth for cis women. Right now I am working back up to using the second largest dialator in the set. While I dont have any trouble in the peritoneal formed portion, the outer area where skin meets peritoneum has had some constriction with not dialating. I can use the second largest one in the set comfortably again.
In general maintaining one time per week now should keep everything fine for me now.

3)Did I develop it with them, not exactly. The Davydov Method has been around for 50 years. Honestly I had lucky circumstances. Dr. Gallagher had posted a YouTube video where she expressed her own interest in the concept. I commented on the video and she answered back. For a time this was as far as I could go due to cost of surgeries. Then at the beginning of 2019 my spouse started a job that had health insurance that fully covered GCS. It took some effort to reach out to the surgical coordinator working the clinic with Dr. Gallagher at first. However I had very specific questions which got passed on to the P.A. working in the clinic. She then had to pass them on to Dr. Gallagher. The PA sent me the responses. I came prepared to discuss PPV with Dr. Gallagher on my first appointment. She was very open to discussing the idea with me. She couldn't move forward then because she had to have a urologist.
A few more emails with the PA and Dr. Gallagher emailed me that she was meeting with her boss and the urology department to discuss it. After that meeting Dr. Gallagher's office made an appointment for me to see Dr. Koch. When I saw him he came in and said he didn't know exactly what was being discussed prior to him seeing me except he told the hospital supervisor he was willing to help Dr. Gallagher if he could. I had all of the PDF's stored on my phone so as I discussed it with him I could email him the documents and links. Dr. Koch opened a few documents and then opened a YouTube tab on the office computer. He was very interested once he saw what these videos showed surgeons doing. These videos all filmed the internal laproscopic camera which is exactly what he does every day. I left there with him saying he would look over the studies and videos and let myself and Dr. Gallagher know. The next week he stated he was willing to try it. Later Dr. Koch told Dr. Gallagher that is was a very simple and easy procedure from his end. She also said its surprising that it hasn't been the standard MTF method for years. I believe I was under for less than 4.5 hours.

So I didn't develop the procedure. I did do a ton of research and went in prepared to discuss it. Fortunately I found doctors and a univeristy hospital that were always looking to learn and teach new ideas.

Now I had some particular requests when it came to keeping my sensate region intact. Dr. Gallagher suggested I research the Chonburi Flap technic as one idea. Later her and I passed some sketches back and forth and it was essentially the way she did my reconstruction.

4) Dr. Matre's work was all done on cis female patients with Mullerian Agenesis. So he did not have to reconstruct the external genitals. He would create an incision where the vaginal opening should be and connect the pulled down peritoneum to there.
What was done to me was identicle internally. Dr. Gallagher had to do the regular MTF resection and then did a modified version of a Chonburi Flap to form my genitals.
To be specific: In a typical penial inversion, the tubular skin of the penis is fully turned inside out and the skin must be pulled down to the vaginal entrance position. Instead what was done was to cut an incision up the lower side stopping a distance from the end. This leaves a tube section of skin at the end but allows the penial shaft skin to be opened out into a semi flat sheet of skin. The flat section is left connected at the top of the base (dorsal side) so blood supply is maintained in the skin. The tube section left at the end is inverted forming a well shape. This forms the vaginal entrance. The peritoneum was then attached to this skin and underneath supporting tissue. Since the end skin of the penis didn't have any hair, no hair removal was needed. This method also did not require pulling and stretching the skin downward like in a penial inversion.

5) if you want to send me a PM through the site I can email the list with links still attached. The videos simply show multiple surgeons all over the world performing laproscopic Davydov procedures. The papers all apply to the basic method.
04/26/2018 bi-lateral orchiectomy
09/11/2019 PPV at IU Health (DaVinci robot laparoscopic Davydov with modified Chonburi Flap) w/ Dr. Gallagher, Dr. Koch, Dr. Roth assisting urology
03/02/2020 revision labiaplasty at IU Health w/ Dr. Gallagher

A lifetime of depression and repressed emotions is nothing more than existence.
I for one want to live now, not just exist!

Offline Nozomi

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Re: Looking at peritoneal vaginoplasty with Dr. Gallagher
« Reply #184 on: September 16, 2020, 11:28:08 pm »
Hi Nozomi,
I will do my best to answer your questions.
...
The papers all apply to the basic method.
Thank you very much for your very detailed and informative reply!! 
Please forgive me if I may ask again in the future about a few parts of your answer due to my lack of understanding.

For Japanese transwomen, could you reply your feelings of experienced people to the following questions?

6.   What is the minimum requirement for penis length for the PPV method you received? (How many inches?)

As for the issues in your replies #107, 109, and 120, you thought that it will take longer to heal on the outside.
7.   Do you think these are common things that happen to everyone?

You have been studying "the PPV method you received" for a long time.
I worried about peritonitis regarding PPV. The inside of the peritoneum is protected from the outside of the body, but if it is connected to the outside of the body by PPV, will the outside air flow into the abdomen?
8.   Would you please let me know if you have any comments?

In the article entitled “Neovagina creation methods and their potential impact on subsequent uterus transplantation: a review”
As for Davydov vaginoplasty, “Functional success rates are reported as 92–93%, with a vaginal length of about 8.5 ± 1.6 cm and low intra‐ and postoperative risks. [11] After 6 months, vaginoscopy and biopsy results demonstrated the presence of iodine‐positive vaginal epithelium; [12] however, there is an increased risk of bladder or intestinal injury (3.8%), postoperative infections, and vaginal prolapse.[7] Further potential complications include a high rate of postoperative vaginal vault granulation (8.7%) and the risk of vaginal stenosis (5.1%). [7] With regard to later uterus transplantation, the suitability of the Davydov method is limited. In the case of postoperative failure, reoperations are difficult and are associated with intra‐abdominal adhesions. The feasibility of uterus transplantation may be impaired by the altered pelvic anatomical structures.”

In “Vaginoplasty: Peritoneal | mosaic”, Dr Wittenberg wrote as follows:
Risks of peritoneal pull-through procedure:
•All the risks of the penile inversion vaginoplasty
•Additional risk of an abdominal laparoscopic procedure, including intra-abdominal organ injury, ileus, herniation, and others
•Flap failure and stenosis
•Unknown long-term outcomes*
9.   Could you give your comments to possible complications and risks in "the PPV method you received"?

My question 3 of yesterday: Is your dilation similar to "Dilating 101 part 2 (video)”?
You can google search the video by "Dilating 101 part 2" AND Mozaic".

Best regards,
Nozomi

Offline josie76

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Re: Looking at peritoneal vaginoplasty with Dr. Gallagher
« Reply #185 on: September 17, 2020, 08:24:06 am »
Thank you very much for your very detailed and informative reply!! 
Please forgive me if I may ask again in the future about a few parts of your answer due to my lack of understanding.

For Japanese transwomen, could you reply your feelings of experienced people to the following questions?



In “Vaginoplasty: Peritoneal | mosaic”, Dr Wittenberg wrote as follows:

9.   Could you give your comments to possible complications and risks in "the PPV method you received"?

My question 3 of yesterday: Is your dilation similar to "Dilating 101 part 2 (video)”?
You can google search the video by "Dilating 101 part 2" AND Mozaic".

Best regards,
Nozomi


Minimum penial skin length: As the way mine was done I would estimate that approx 2-3" of penial skin tube after "degloving" from the penial interior would be all that is required. Since this skin flap is placed directly downward the penial skin is used for the labia creation.

Dr. Gallagher uses the urethra opened up to form the floor of the vestibule. Many surgeons do this. However the one area that I am not thrilled about with my surgery is that Dr. Gallagher keeps some of the spongiform tissue attached to the urethra. This is semi erectile tissue. This has been my only complaint.

Yes healing the external skin grafts take the longest. For me the self dissolving sutures we dissolved very quickly by my body. This let the skin shift before it had fully reattached to the tissue underneath. So this resulted in some skin graft death and some granulation in those areas. This is what took longer. If the stitches had lasted longer then I might have healed quicker.

7-8) Internally healing happens at its own pace. The peritoneum will self seal if you don't stop it from doing so by dialation up until the internal surface epthilizes. The process of epthilizing seems to depend on air exposure. I was told to use a douche of warm water and a couple drops of iodine solution in the shower at first. Later this was not needed.

Risks: yes there are all the initial complication risks of having genital reconstructive surgery. Then there are risks of any laproscopic surgery. Having skilled doctors are the best insurance in either situation. My urologist uses a davinci surgical robot. He commented that it is like having his hands right inside the body where old laproscopic tools definitely require a very steady hand as those tools are around 2 feet long. If done correctly the Davydov has very low complication rate.

It may help to understand the way the Davydov is done. The surgeon must loosen the peritoneum from the abdominal wall area and the bladder. According to my doctor they do not try to loosen it from the back side around the large intestine. The doctor then finds the lowest place in the lower pouch of the peritoneal cavity. The GCS surgeon would have made sure there was an opening from the exterior and they insert a hook tool. This grabs the opening in the peritoneum and pulls this down. This forms a tube. The laproscopic surgeon then gathers the peritoneum lining together to close the new vaginal tube off from the body cavity and pulls it closed with a "purse suture". This leaves the vaginal tube connected to the main peritoneum lining maintaining blood flow. So this tissue is not "harvested" in a conventional sense but just pull down to repurpose it. The internal end of the vaginal tube is closed so no there is no leaking of the body fluids. The risk of death of the peritoneum vaginal lining is next to 0 as it remains connected to blood flow. Other methods may cut out and use tissue but this method does not remove it.

Vaginal stenosis risk is next to none so long as you dialate. Once the lining epthilizes it will no longer shrink or seal closed. This leaves just skin at the opening at risk of stenosis. Risks of bladder or colon perforations are dependent on the laproscopic surgeon. Vaginal vault granulation is essentially eliminated by using the PPV method.

Long term outcomes are well known for the basic procedure. What the medical community does not have is long term followups on trans-women with this method.

The one thing I can say is having a skilled laproscopic urologist is important. Dr. Koch works inside the peritoneum weekly. For him the procedure was very simple and easily done.
04/26/2018 bi-lateral orchiectomy
09/11/2019 PPV at IU Health (DaVinci robot laparoscopic Davydov with modified Chonburi Flap) w/ Dr. Gallagher, Dr. Koch, Dr. Roth assisting urology
03/02/2020 revision labiaplasty at IU Health w/ Dr. Gallagher

A lifetime of depression and repressed emotions is nothing more than existence.
I for one want to live now, not just exist!

Offline Nozomi

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Re: Looking at peritoneal vaginoplasty with Dr. Gallagher
« Reply #186 on: September 17, 2020, 04:34:56 pm »
Minimum penial skin length:...
The one thing I can say is having a skilled laproscopic urologist is important. Dr. Koch works inside the peritoneum weekly. For him the procedure was very simple and easily done.

Thank you very much for the detailed explanation that conveys the image!!

I am very grateful for your answer.

Offline Nozomi

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Re: Looking at peritoneal vaginoplasty with Dr. Gallagher
« Reply #187 on: September 20, 2020, 09:46:06 pm »
1-2)…At 6 months I would say about 50-70% of the depth of the peritoneal lining was epthilized.

7-8) Internally healing happens at its own pace. The peritoneum will self seal if you don't stop it from doing so by dialation up until the internal surface epthilizes. The process of epthilizing seems to depend on air exposure.….
Once the lining epthilizes it will no longer shrink or seal closed.

10. I talked about PPV with a Japanese MTF friend.
She told that the peritoneal area is thin, so strong dilation is not possible, and there is a problem with sexual behavior.
I told her that the peritoneal tissues are epithelized and become almost indistinguishable from natal vaginal lining tissues after 6 month to a year.

What would you answer to her red words?

11.  In your reply #4 of the forum “Laparoscopic peritoneal pull-through vaginoplasty- testimonials, anyone?”,
“Some later studies following patients of peritoneal vaginoplasty showed that the peritoneal tissues become almost indistinguishable from natal vaginal lining tissues after 6 month to a year.
Is it Dr. Mhatre's paper of ”New laparoscopic peritoneal pull-through vaginoplasty technique”? If not, could you tell me the title of the paper? The Dr. Mhatre's paper is for ciswomen. Could you tell me the paper for transwomen?

12. The epithelized peritoneum is tough, right?

13. On the premise of the above quoted part, Before epithelization, should dilation be softly? How did you dilate in the very early stage and next duration?

Best regards,
Nozomi

Offline josie76

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Re: Looking at peritoneal vaginoplasty with Dr. Gallagher
« Reply #188 on: September 21, 2020, 08:19:43 am »

Nozomi

Study list. I tried putting <dot> in place of an actual "." to kill the links.

Badran, Osama. MD, FACOG. Laparoscopic Neovagina Creation – with audio. 2012, Oct 30. Amman,
Jordan. www.drbadran.com. Video Retrieved from YouTube
Dr. Badran is a American Board Certified Gynecologist with a sub-specialty degree in Advanced Laparoscopic Gynecologic Surgery. He was chairman of the Gynecology Department at Interfaith Medical Center/New York 2001-2004 and has been a consultant in Gynecologic Oncology at King Hussein Cancer Center in Amman-Jordan since 2005. His private practice limited to advanced laparoscopic and minimally invasive gynecologic surgery. Dr. Badran demonstrates a laparoscopic Davydov procedure. This patient is female at birth. She has MRKH syndrome with fully formed ovaries but agenesis of the uterine and vaginal tissues. When Dr. Badran begins on the external genitals, it is clear the patient lacks even the vaginal introitus. Dr. Badran begins with an incision to open an introitus. He then opens the space for the vaginal canal until the dialator being used can be seen on the laparoscope pressing against the peritoneal pouch. This provides a visual location to open the peritoneal tissue inside. The peritoneal tissue around the incision point is mobilized. This does not appear to require a large area. After mobilization and opening to the new vaginal space, the peritoneum is grabbed and pulled down to the neo-vaginal introitus. The peritoneal tissues are sutured to the introitus. Then inside the laparoscopic surgeon uses a stitch to gather and pull the anterior of the neo-vaginal canal closed. This closes the peritoneal cavity as well. This case may be of particular interest as the patient has no existing vaginal introitus and therefore no existing depth to work from. This will be similar to a patient who is assigned male at birth from the external side.

Chittawar, Priya Bhave. Laparoscopic Vaginoplasty: Davydov's procedure. 2012, Oct 4. Video Retrieved from YouTube
Dr. Chittawar does a audio walk through of the procedure. She explains each step in detail as needed in this video. Dr. Chittawar explains several benefits to this procedure: Good vaginal depth. Does not require long term post operative dialation. Good epithelization from the peritoneal lining. Can be done by surgeon with average laparoscopic skill.

Dadhich, Chandra P. OBGYN. Laparoscopic vaginoplasty by peritoneal pull through by C.P.Dadhich. 2015,
July 3. Jaipur, India. Video Retrieved from YouTube
Dr. Dadhich performs a laparoscopic Davydov procedure. This patient is female at birth with MRKH syndrome. She has partial depth vaginal tissue.

Dadhich, Chandra P. OBGYN, Dadhich, Tripti. OBGYN. Dr. DADHICH technique of Peritoneal tube neo
vaginoplasty(5). 2019, Feb 17. Jaipur, India. Video Retrieved from YouTube
Dr. Dadhich demonstrates a laparoscopic Davydov procedure on a female at birth patient.

Watson, Jane. PriyaMED presents... Sugar's PPV GRS SRS GCS Vaginoplasty. 2018, Aug 24. Mumbia, India. Video Retrieved from YouTube
-The doctors in Mumbia, India demonstrate the use of a laparoscopic Davydov procedure on a trans-woman. They combine the pull through peritoneal technique with a non- penile inversion genital reconstruction. This patient is male at birth and has no visible signs of feminine skeletal traits. This patient has a normal male type pelvic structure. This is one of three patients to get this surgery in 2018. The hospital is opening this as a full option for GCS patients in 2019.

Journal Articles:

Bianchi, Stefano., Berlanda, Nicola., Brunetto, Federica., Bulfoni, Alessandro., Caroggio, Celcilla., Fedele, Luigi.
Creation of a Neovagina by Laparoscopic Modified Davydov Vaginoplasty in Patients with Partial
Androgen Insensitivity Syndrome. The Journal of Minimally Invasive Gynecology. 2017, Nov-Dec. Vol 24,
Issue 7, pages 1211-1217.

-This study reviewed a number of patients who had different grades of Partial Androgen Insensitivity Syndrome (PAIS). These patients are XY but have varying inability to react to androgen hormones. Androgen Insensitivity is divided into seven grades based on the degree of visible genital deformity effect. Currently the medical database has near 700 known mutations to the AR gene. This study was done by the Dipartimento di Ostetricia e Ginecologia e Universita degli Studi di Milano, Ospedale San Giuseppe, Milan, Italy and shows the Davydov procedure being used with genital reconstruction with patients who fit into ambiguous genitalia. Most lack any existing vaginal dimple or depth.


Fedele, L., Frontino, G., Restelli, E., Ciappina, N., Motta, F., Bianchi, S. . Creation of a neovagina by
Davydov's laparoscopic modified technique in patients with Rokitansky syndrome.

Giannesi, A., Marchiole, P., Benchaib, M., Chevret-Measson, M., Mathevet, P., Dargent, D. Sexuality after
laparoscopic Davydov in patients affected by congenital complete vaginal agenesis associated with
uterine agenesis or hypoplasia. Human Reproduction, Volume 20, Issue 10, October 2005, Pages 2954–
2957

Jalalizadeh, Mehrsa, MD; Shobeiri, S. Abbas, MD, MBA. Davydov Procedure for Augmenting Vaginal Length
in a Postsurgical Male-to-Female Transgender Patient. Female Pelvic Medicine & Reconstructive Surgery:
July/August 2018 - Volume 24 - Issue 4 - p e9–e11.

Khadka, R.R., Islam, S., Rahman, S., Ali, Y., Salam, M.A., Hossain, M., Hasan, S., Vaginoplasty in vaginal
agenesis associated with MRKH syndrome with tabularized peritoneal pull-through. A Journal of
Bangabandhe Sheikh Mujib Medical University, Dhaka, Bangladesh. 2017, issue 10, pages 35-37.

Marton, Ingrid., Habek, Dubravko., UjeviÄ, Boris. Laparoscopic Davydov procedure: 4 cases of
neovaginoplasty. ISGE 25th Annual Congress & 4th Croatian Congress. 2016, May 25-28.

Mahtre, Pravin., Mahtre, Jyoti., Sahu, Rakhi. New laparoscopic peritoneal pull-through vaginoplasty
technique. Journal Human Reproductive Science. 2014, Jul-Sept. Pages 181-186.

Slater, Michael W., Vinaja, Xochitl., Islam, Aly., Loukas, Marios., Terrell, Mark., Schober, Justine. Neovaginal
Construction with Pelvic Peritoneum: Reviewing an Old Approach for a New Application. Clinical
Anatomy. 2018. issue 31. pages 175–180.

Takahashi, K., Nakamura, E., Suzuki, S., Shinoda, M., Nishijima, Y., Ohnuki, Y., Kondo, A., Shiina, T., Suzuki, T.,
Izumi, S., Laparoscopic Davydov Procedure for the Creation of a Neovagina in Patients with Mayer-
Rokitansky-Kuster-Hauser Syndrome: Analysis of 7 Cases. Tokai Journal of Experimental and Clinical
Medicine. 2016 Jun 20;41(2):81-7.

Images sourced, Laparoscopic Davydov Neovagina. Milkos and Moore.

04/26/2018 bi-lateral orchiectomy
09/11/2019 PPV at IU Health (DaVinci robot laparoscopic Davydov with modified Chonburi Flap) w/ Dr. Gallagher, Dr. Koch, Dr. Roth assisting urology
03/02/2020 revision labiaplasty at IU Health w/ Dr. Gallagher

A lifetime of depression and repressed emotions is nothing more than existence.
I for one want to live now, not just exist!

Offline josie76

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Re: Looking at peritoneal vaginoplasty with Dr. Gallagher
« Reply #189 on: September 21, 2020, 08:35:40 am »
10. I talked about PPV with a Japanese MTF friend.
She told that the peritoneal area is thin, so strong dilation is not possible, and there is a problem with sexual behavior.
I told her that the peritoneal tissues are epithelized and become almost indistinguishable from natal vaginal lining tissues after 6 month to a year.

What would you answer to her red words?

12. The epithelized peritoneum is tough, right?

YES, once epthilized it is quite strong and elastic. :) Rougher use of toys is quite possible.
Actually the peritoneum must be quite tough according to the urologist who did mine. Its tough enough to hold up when they use a laproscopic claw to pull it loose around the abdominal cavity. The claw looks like a alligator tooth wire clip.

13. On the premise of the above quoted part, Before epithelization, should dilation be softly? How did you dilate in the very early stage and next duration?

Dialation was explained to me simply. Insert the dialator and hold firm pressure against the end for about 20 min per session. Nothing but direct pressure. This keeps the vaginal canal open while epthiliaztion takes place.
Dialation is important as it prevents the peritoneum tissue from forming webbing and healing closed.

04/26/2018 bi-lateral orchiectomy
09/11/2019 PPV at IU Health (DaVinci robot laparoscopic Davydov with modified Chonburi Flap) w/ Dr. Gallagher, Dr. Koch, Dr. Roth assisting urology
03/02/2020 revision labiaplasty at IU Health w/ Dr. Gallagher

A lifetime of depression and repressed emotions is nothing more than existence.
I for one want to live now, not just exist!

Offline josie76

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Re: Looking at peritoneal vaginoplasty with Dr. Gallagher
« Reply #190 on: September 21, 2020, 10:19:38 am »
Nozomi

Not sure if these pics are OK but its one letter I sent to Dr. Gallagher when discussing this.


page1

page2

page3

page4edit

04/26/2018 bi-lateral orchiectomy
09/11/2019 PPV at IU Health (DaVinci robot laparoscopic Davydov with modified Chonburi Flap) w/ Dr. Gallagher, Dr. Koch, Dr. Roth assisting urology
03/02/2020 revision labiaplasty at IU Health w/ Dr. Gallagher

A lifetime of depression and repressed emotions is nothing more than existence.
I for one want to live now, not just exist!

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Re: Looking at peritoneal vaginoplasty with Dr. Gallagher
« Reply #191 on: September 21, 2020, 05:27:09 pm »
Nozomi
Not sure if these pics are OK but its one letter I sent to Dr. Gallagher when discussing this....

My appreciation can’t be expressed in words for sharing your invaluable personal communication with figures.
You are great developer!
I understand "Not sure if these pics are OK".

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Re: Looking at peritoneal vaginoplasty with Dr. Gallagher
« Reply #192 on: September 21, 2020, 05:49:11 pm »
YES, once epthilized it is quite strong and elastic. ...
13. ...Dialation was explained to me simply....

I appreciate your answers !

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Re: Looking at peritoneal vaginoplasty with Dr. Gallagher
« Reply #193 on: September 21, 2020, 05:50:53 pm »
Study list. I tried putting <dot> in place of an actual "." to kill the links.

Thank you very much for sharing your study list.
It is extremely regrettable that it is buried in the comment section of youtube, and it is suitable for this site.

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Re: Looking at peritoneal vaginoplasty with Dr. Gallagher
« Reply #194 on: September 25, 2020, 03:01:02 am »
Nozomi  Not sure...

14.I found and saw all the Dr. Suporn presentation (Dec 2004) in last page of your letter. 
In your signature, “modified Chonburi Flap”. Could you tell me the details of the modification? Here, I realize your easy-to-understand following.explanation

For my procedure I had Dr. Koch the urology chair doing the laproscopic potion. They place 5 small incisions in my belly to insert a robotic surgical tool.
  Dr. Gallgher di the disassembly of the penile tissue. This is much the same for most surgeons. She kept the frenulum area per my request to make the clitoris from. This stays connected to blood vessels and nerves. She uses a length of the urethra from the inside of the penis as the vestibule floor. Also fairly common practice. My labia are made mostly of penile skin.
Internally, Dr. Koch went to the bottom of the space behind the bladder. Opened a small incision through the peritoneal  lining from the inside. He also had to loosen the lining from the inner wall of the abdominal cavity. This then allows them to insert a hook tool and pull the peritoneum lining down to the opening created by the GCS surgeon for the vaginal introitus. The pull the peritoneum down forming a tube and stitch this to the vaginal opening. The laproscopic surgeon then closes the tube inside the body with a "purse stich" suture. This closes the vaginal cavity while leaving it completely attached to the rest of the peritoneum. This way there are no concerns about loss of blood supply to this tissue.

15.   In your signature, “DaVinci robot laparoscopic Davydov”, I realize the benefits of robot.
Are there any precautions (areas or procedures, etc.) specific to PPV Da Vinci robotic laparoscopic surgery?

16.   If the penile skin isn't enough for PPV, could you please comment on the use of scrotal skin or inguinal skin to compensate it, as in Dr Suporn's presentation? Here I know you didn't need it, and you wrote as follows:

A number of doctors will use scrotal skin with this same type of tissue still connected to form the bottom part of a penile inversion as a standard practice. However you still have a length of regular penile skin first. Also neither surgical style does away with internal scar issues when healing.

From Dr. Suporn's description, the dorsal side of the penial skin is left connected at the base and layer in as the floor of the vestibule. Dr. Suporn makes a neoclitoris complete with frenulum and labia minora connected to the frenulum. From what I have found, he stops short of describing how he builds the vagina except he says he uses penial and scrotal skin. With a Peritoneal pull through the most that might be needed is skin at the vaginal introitus. I thought perhaps the end of penial tube after being degloved could form this if it is needed. I will know more when I see Dr. Gallagher again on my surgery day.  Anyway, the penial skin is thin and has no subcutaneous fat so it is ideal to create the labia minora, and clitoral hood out of.




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Re: Looking at peritoneal vaginoplasty with Dr. Gallagher
« Reply #195 on: September 25, 2020, 05:50:23 pm »
Nozomi

14) my surgery was done almost as I had drawn the pictures in my letter. Dr. Gallagher did keep the frenulum and that skin is exposed right were the clitoris should be.
The difference: Dr. Suporn makes the frenulum into a small structure looking just as a cis clitoris. He gathers skin to shape labia minora on each side and connects that skin fold to the frenulum on each side of center. When healing occurs this leaves a very natal appearance to the neo-clitoris and labia minora. Dr. Gallagher however also keeps opened urethra to line the bottom center with. Many other surgeons also use this. Dr. Gallagher leaves some of the corpus spongisium behind the urethra. This has been the one issue for me. I think there is too much of this tissue there since it is semi erectile.

15) no there is nothing specific to robotic surgery. For the doctor this is far more precise and likely safer for the patient than the old style laproscopic tools used. The old tools are each about 2 feet long and the surgeon must operate them from the one end with their thumbs. The robotic surgery makes the surgeons control much more stable inside the body.

16) since the vaginal canal is made of peritoneum and not skin, very little penile skin is needed. For the most part skin is only used for the external genital reconstruction. If skin is in short supply then areas of the inside of the vestibule can be made of peritoneum as well. Otherwise scrotal skin could be used.

04/26/2018 bi-lateral orchiectomy
09/11/2019 PPV at IU Health (DaVinci robot laparoscopic Davydov with modified Chonburi Flap) w/ Dr. Gallagher, Dr. Koch, Dr. Roth assisting urology
03/02/2020 revision labiaplasty at IU Health w/ Dr. Gallagher

A lifetime of depression and repressed emotions is nothing more than existence.
I for one want to live now, not just exist!

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Re: Looking at peritoneal vaginoplasty with Dr. Gallagher
« Reply #196 on: September 25, 2020, 09:19:34 pm »
Nozomi 14) 15) 16)

As my posts are less than 50, I can not give reputation points.
So I wish to offer my immeasurable gratitude to you not only for this answer, but for all your answers so far.

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Re: Looking at peritoneal vaginoplasty with Dr. Gallagher
« Reply #197 on: October 05, 2020, 11:37:14 pm »
So Dr. Gallagher used to require clearing of hair. Now she does not.

Dear Josie,
17.   Would you please select numbers from the list below that is not included in preoperative requirements for your PPV surgery at IU Health? 6,

In “Vaginoplasty: Peritoneal | mozaic - Dr. Heidi Wittenberg”.
PREOP REQUIREMENTS for peritoneal pull-through vaginoplasty include:
1. Three letters (2 from mental health professionals, 1 from a hormone provider or primary care doctor).
2. Overall good health.
3. No smoking, nicotine, or any other inhalational products (including second hand smoke) around 3 months before and after surgery. This can cause about a 5-fold increase in complications. Patients who smoke within this 3 month window before surgery may be rescheduled for a later time when then they have reliably stopped smoking.
4. Perioperative assistance (friends, family, hired help).
5. Surgical technique, anatomy, and genetics dictate most of the individualized aesthetic results.
6. Hair removal (same guide for a vaginoplasty procedure).
7. No prior abdominal mesh surgery.
8. No prior exploratory laparotomy for trauma.
9. No prior history of pelvic radiation.
10. No prior history of inflammatory bowel disease. No Crohn's disease, ulcerative colitis, or diverticulitis.

Minimum penial skin length: As the way mine was done I would estimate that approx 2-3" of penial skin tube after "degloving" from the penial interior would be all that is required. Since this skin flap is placed directly downward the penial skin is used for the labia creation.

16) since the vaginal canal is made of peritoneum and not skin, very little penile skin is needed. For the most part skin is only used for the external genital reconstruction. If skin is in short supply, then areas of the inside of the vestibule can be made of peritoneum as well. Otherwise scrotal skin could be used.

18.   “Approx 2-3" (Personal Estimate) of penial skin tube after "degloving" is preferable. If skin is in short supply peritoneum or scrotal skin supplements it. So penis length is not preoperative requirement.” Is my understanding correct?

19.   Could you please indicate numbers that does not apply to your PPV at IU Health in the following points?

In “Vaginoplasty: Peritoneal | mozaic - Dr. Heidi Wittenberg”.
Potential benefits of this option (peritoneal pull-through procedure):
1.   Self-lubricating lining with some elasticity
2.   Less need for dilation (compared to that of the penile inversion technique)
3.   Less need for douching
4.   Less preop hair removal
5.   More vaginal depth
6.   Lower risk than colonic vaginoplasty
Risks of peritoneal pull-through procedure:
7.   All the risks of the penile inversion vaginoplasty
8.   Additional risk of an abdominal laparoscopic procedure, including intra-abdominal organ injury, ileus, herniation, and others
9.   Flap failure and stenosis
10.   Unknown long-term outcomes*

Dr. Ting's notes that have been talked about does not use a peritoneal tube from a Davydov procedure….
Another surgeon at NYU has done a peritoneal cap procedure. ,,, but it is still a skin based vaginal cavity.

20.   Yesterday I found “overview for Setiku – R...”: In it,
“Djordjevic in Serbia, Houtmeyers in Belgium. Outside of USA and Europe are Kamol in Thailand and PriyaMed in India”
“…I'm personally leaning towards Kamol for the peritoneal option, he is currently my strongest contender,…I think there are multiple variants of peritoneal as a technique - the one described in the Susan's thread 2) seems to not be 'pull-through',”
though the description in SRS-PPV (Penile-Peritoneal Vaginoplasty) of “MTF Sex Reassignment Surgery - Kamol Cosmetic Hospital” seems to be similar to that of PPV. I have shown the part below 1) for your convenience.
I was able to confirm that the lower half of the vaginal tube was made of penile skin and the upper half was made of peritoneum.
As shown in the above quote, you have commented on Ting and others.
Would you give me your comment to the followings?
A) Can it be expected that “half the peritoneum and half the penis” will keep dilation easier?
B) The potential risk of “half the peritoneum and half the penis”
C) The points to distinguish between the surgery that has the “potential benefits” in question #19 and those does not have them


1) Penile-Peritoneal Vaginoplasty technique (SRS-PPV) (2020-10-05 14:17. This PPV is new at Kamol, so this page may be updated, pink is my comment.)
           This technique is the most current advanced technique and innovation of neovaginoplasty for transwomen. The peritoneum is cut and pulled through the neovaginal canal with laparoscopic method. The penile skin sutured with the peritoneum at the neovaginal entrance.
           The neovagina will have self lubricate resemble the biologic female. The neovagina is less chance of shrinkage, less chance of vaginal prolapse. It needs vaginal dilation less than skin graft or colon technique due to the nature of the peritoneum mucosa. This technique is a benefit for those who have chronic colitis (Crohn’s disease) or chronic diverticulitis. Also, that's no hair growth at the deep part of the neovagina. Using combined penile skin and peritoneal mucosa technique will decrease excessive mucous and less chance of prolapsed penile flap. The operation time takes 4-6 hours.
Advantages:
1.   This technique can use as a primary or secondary neovagina reconstruction.
2.   This technique is beneficial for patients who have previously undergone sex reassignment surgery, penile inversion whose vaginas have become a loss of depth, and are unable to perform sexual intercourse.
3.   The vagina has a self-natural lubricant.
4.   Easier to do vaginal dilation than skin graft technique.
5.   Fewer risks of intestinal dysfunction compare to the sigmoid colon.

2) I searched the Susan's thread, but I could not find it.
PPV of SRS at Kamol Hospital began in 2020 (practically after summer).
But I could find only
https://www.susans.org/forums/index.php/topic,245400.msg2263812.html#msg2263812 June 12, 2019, FSS not SRS
https://www.susans.org/forums/index.php/topic,234185.msg2216794.html#msg2216794 January 21, 2019
https://www.susans.org/forums/index.php/topic,237694.msg2141209.html#msg2141209 original quote is May 30, 2018 and deleted
the others are older than the above posts.
 
Best regards,
Nozomi

Offline josie76

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Re: Looking at peritoneal vaginoplasty with Dr. Gallagher
« Reply #198 on: October 06, 2020, 10:03:40 am »

Nozomi,

17) items not required at IU Health
-hair removal; I had no removal required as the penile skin has very little hair except at the base. This may vary for some patients. Since the end of the skin tube formed the introitus there was no hair issue.

-No prior abdominal mesh surgery; I had previous hernia surgery and had a mesh and staples, no problems
image
You can see the staples are the shiny dots in this CT of me.

-No prior exploratory laparotomy for trauma; Again my urologist said no problem with my hernia repair surgical hardware so not an issue

-No prior history of pelvic radiation; no idea about this one

I do not know the doctors opinion of inflamatory bowl syndromes.


18) yes, if needed any skilled surgeon can pull the peritoneum further down and out or they can harvest the same type of tissue from inside the testicular bag. When the testes push through the abdomen they pull along a bag of peritoneal tissue from the abdomen.


19) things that do not apply
9; really failure of peritoneal flap should have a zero occurence when done as the davydov procedure. This is because the peritoneal lining is still connected completely to the abdominal main part of the peritoneum. All blood flow continues as normal through this tissues. external skin flap death does happen. I had places the dissolving stitches were destroyed too quickly by my body and the skin pulled back opening the underlayer of tissue. The skin that pulled back died since it had not fully connected new blood vessels from the tissue under it. This causes granulation to then form until it heals in as new skin. This was all external issues for me.
10; Dr. Milkos and Dr. Moore have been doing the Davydov in the US for three decades now. They just didn't perform it on trans patients. Medical outcomes are well known for this surgery. The warning from some doctors is simply when it comes to "transwomen" there is very little history. There has been some documentation of it being used on higher grade PAIS patients in liue of colon or illeal types of surgeries.


20)
A) Using the peritoneum as just the bottom half may make dialation easier. You still have to get past the point of granulation at the edge of the skin to peritoneum transition. If this area proves an issue then the peritoneum depth may be lost as without dialation it will heal closed. This is until full epthiliation has happened. On the positive side, with the deeper half pertoneum there will be no pain from granulation at full depth.

B)I could see a potential risk early on of the skin having granulation at the joint and possible tear. That would be similar risk to a all skin spliced with scrotal skin penial inversion where there are deep joints with skin flaps.

C) The way mine was done, the skin and peritoneum meet right at the first layer of pelvic floor muscle. This I think provided a very good underlying tissue to joint both part to. This makes the skin section very shallow and the remainder full peritoneum. This point has also been my only issue when I skipped dialation for several weeks due to some extreme personal family issues happening around me. I am getting back my girth and depth now with dialation.

A surgery that does a full penial inversion and then joins peritomeum to it still has advantages over just skin inversion. However there will be risk of issues at the deeper tissue joint while healing. There is more potential for issues of hair depending on the patient and the length inverted. Penial inversion requires pulling the skin on the outside much more as well and there are issues possible with the seems there and with needed further skin removal later.

Dr. Ting has done a graft of peritoneum tissue removed from the testicular pocket. His version required removing this tissue from the body then grafting it as an internal layer to a skin graft. This placed peritoneum like lining into a skin made vaginal cavity.
Another NYU doctor has done some with simply stitching the ends of the open inverted skin tube to the abdominal peritoneum. Essentially this makes a peritoneum cap at the end of a skin made vaginal cavity.
Since then NYU has also done some Davydov style revisions of low depth penial inversions. I have not read that they have done any as the full primary surgery.

Risk wise, with a capable urologist there is far less risk with a Davydov than with either an illeal (small intestine, almost never mentioned in literature for some years) or colon. Colon has been done by some surgeons with decent results. However the risk of cutting a section of colon out and then making the two ends of the original connect back together without leaking potentially harmful bacteria is quite higher.

The more of the peritoneum that can be used for the vaginal cavity the better I think. It doesn't "feel" like skin. It quite literally has the tactile surface of a cis vagina.

04/26/2018 bi-lateral orchiectomy
09/11/2019 PPV at IU Health (DaVinci robot laparoscopic Davydov with modified Chonburi Flap) w/ Dr. Gallagher, Dr. Koch, Dr. Roth assisting urology
03/02/2020 revision labiaplasty at IU Health w/ Dr. Gallagher

A lifetime of depression and repressed emotions is nothing more than existence.
I for one want to live now, not just exist!

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Re: Looking at peritoneal vaginoplasty with Dr. Gallagher
« Reply #199 on: October 06, 2020, 04:23:32 pm »
Nozomi, 17) 18) 19) 20)

Thank you very much for your reply.
From the bottom of my heart,
I'm very glad to hear your deep insight.