Sk office 's Entries

5 blogs
  • 03 Oct 2018
    People should certainly get whole advantageous asset of drugstore review internet sites that could give them data regarding generic medicine providers. Determining the best generic medicine supply might help persons save your self plenty of cash with medical expenses. The expense of medication today has considerably grown, which makes it significantly more difficult for a lot of individuals to manage their expenses. Fortuitously, you should buy drugs on the web from pharmacies that could give people who have cheaper medication. A lot of these on the web medicine shops operating nowadays provide their products and services at a cheap due to the decrease handling costs of sites. Several of these those sites also provide good quality generic medicine. Common medicine is much less expensive, and presents similar effects as their branded counterparts. Pharmacy review those sites might help people find reliable on the web pharmacies to buy drugs on the Dispensary Near Me. This can guide everyone get the best medicines accessible without reducing their privacy and the safety of their financial details. There are plenty of drugstore review those sites that could give a wealth of data regarding generic on the web pharmacies. These internet sites are perfect for persons seeking to truly save an essential amount of cash inside their medication expenses. The several types of generic medicine accessible nowadays purpose the same way as their branded variants, but not absolutely all products and services could possibly be trusted. Finding reliable and reputable resources via generic drugstore evaluations might be sure that individuals are safe making use of their purchases and that the item they buy work. These on the web drugstore evaluations feature many different on the web pharmacies, giving persons world wide all the facts required before they buy drugs online. Because these review internet sites rely on an on the web community of consumers, they are able to certainly guide you to locate the best on the web drugstore. Without these important evaluations, you is only going to learn about the online drugstore depending on its promotional initiatives, which aren't always true. Online drugstore review internet sites can actually change lives in the lives of folks. Besides offering generic drugstore evaluations and feedback, such drugstore courses give safety and safety for on the web consumers. Few are aware that there are several con those sites today pretending to be on the web medicine stores. These internet sites employed in offender activities will look very reliable to many customers searching for medication on the web, and have positively victimized a lot of simple consumers before. Finding important data about the validity of specific on the web pharmacies might help persons steer clear of fraudulent sites. Pharmacy review those sites have already served a lot of on the web customers from such situations, therefore those folks who are just fresh to buying medication from on the web medicine shops must really contemplate visiting such those sites first for his or her safety. Pharmacy review those sites have certainly presented many different benefits and benefits to people over the world. So many individuals are actually viewing the real value of such web sites. Once you really should get drugs on the web, make sure you have a glance at these review internet sites first. They are able to provide you with a sooner search of that on the web drugstore you wish to purchase your medicine from. If that site is reliable, these review internet sites will surely talk highly of it.
    1035 Posted by Sk office
  • People should certainly get whole advantageous asset of drugstore review internet sites that could give them data regarding generic medicine providers. Determining the best generic medicine supply might help persons save your self plenty of cash with medical expenses. The expense of medication today has considerably grown, which makes it significantly more difficult for a lot of individuals to manage their expenses. Fortuitously, you should buy drugs on the web from pharmacies that could give people who have cheaper medication. A lot of these on the web medicine shops operating nowadays provide their products and services at a cheap due to the decrease handling costs of sites. Several of these those sites also provide good quality generic medicine. Common medicine is much less expensive, and presents similar effects as their branded counterparts. Pharmacy review those sites might help people find reliable on the web pharmacies to buy drugs on the Dispensary Near Me. This can guide everyone get the best medicines accessible without reducing their privacy and the safety of their financial details. There are plenty of drugstore review those sites that could give a wealth of data regarding generic on the web pharmacies. These internet sites are perfect for persons seeking to truly save an essential amount of cash inside their medication expenses. The several types of generic medicine accessible nowadays purpose the same way as their branded variants, but not absolutely all products and services could possibly be trusted. Finding reliable and reputable resources via generic drugstore evaluations might be sure that individuals are safe making use of their purchases and that the item they buy work. These on the web drugstore evaluations feature many different on the web pharmacies, giving persons world wide all the facts required before they buy drugs online. Because these review internet sites rely on an on the web community of consumers, they are able to certainly guide you to locate the best on the web drugstore. Without these important evaluations, you is only going to learn about the online drugstore depending on its promotional initiatives, which aren't always true. Online drugstore review internet sites can actually change lives in the lives of folks. Besides offering generic drugstore evaluations and feedback, such drugstore courses give safety and safety for on the web consumers. Few are aware that there are several con those sites today pretending to be on the web medicine stores. These internet sites employed in offender activities will look very reliable to many customers searching for medication on the web, and have positively victimized a lot of simple consumers before. Finding important data about the validity of specific on the web pharmacies might help persons steer clear of fraudulent sites. Pharmacy review those sites have already served a lot of on the web customers from such situations, therefore those folks who are just fresh to buying medication from on the web medicine shops must really contemplate visiting such those sites first for his or her safety. Pharmacy review those sites have certainly presented many different benefits and benefits to people over the world. So many individuals are actually viewing the real value of such web sites. Once you really should get drugs on the web, make sure you have a glance at these review internet sites first. They are able to provide you with a sooner search of that on the web drugstore you wish to purchase your medicine from. If that site is reliable, these review internet sites will surely talk highly of it.
    Oct 03, 2018 1035
  • 29 Sep 2018
    All the individuals are involved to purchase prescription medications online from their comfortable home. With the development of internet engineering, the web shopping has been rising and so many individuals are thinking about shopping through the internet. You need to consider so many things before getting a reliable pharmacy keep in internet. When you're buying prescription medications online, you should workout some warning and do your study to ensure you get that which you spend for. These few lines will help you to discover a trustworthy online pharmacy. The initial position you have to search for is an detailed internet pharmaceutical. The absolute most reliable pharmacy pages have the ability to comprehensively tell visitors regarding their inventory, pricing, and paid off charge offers. They must be strong about showing people these features. If the costs and models appear inaccurate and obscure, do not trouble your self getting from the website. Reliable websites also provide detailed informative data on the recent medicine study and helpful recommendations on getting medicine online. There are numerous benefits to purchasing medications from online pharmacies. On the web pharmacy buys are most beneficial to seniors, handicapped persons, and citizens of rural towns. The seniors don't need certainly to worry about an exhausting journey to the neighborhood pharmacy. People of a long way away towns can only drop by the medicine keep web site and watch for their buy to be delivered. Apart from their ease, online pharmacies value medications at inexpensive costs. Individuals who need to save for operative procedures and other solution remedies can reduce rates by getting medications from the web. As opposed to regional pharmacies, pharmacy websites also provide detailed facts concerning the medications they are supplying. As you ]browse the internet site, every accessible solution involves a thorough account. This feature is certainly helpful for these under maintaining treatment. To start with, when you are buying prescription medications online, you will need contemplate that they need to have certification. Something we need remembers that trustworthy online pharmacies around the globe must present a valid international pharmacy association certification. This will assure the pharmacy meets all international rules and laws. The following items to contemplate that check evaluation sites. Now, the net will help you, see what other folks assert in regards to the pharmacy you intend to purchase from. Always get evaluations with a grain of salt, but usually if the web pharmacy has a lot of positive reviews, you may even have a good experience getting from them. After that you'll require to look for their receptive methods. Chances are if your true individual reacts to the web pharmacy email, or they have a stay support chat, you can get greater company as it shows which they worry about their customers. Discover the web pharmacy's contact data and give them a call or deliver them an email along with your questions. And you also need to test that do they need your doctor's membership or not. Dependable prescription medications online stores will need that you've a valid prescription for the medications your seed to buy. Please be sure that they need it for all medicine purchases. Ultimately, you will need to test that have they experienced company long. See the length of time this online pharmacy has been working for. And you also need to consider that shops they could be related with. The lengthier the pharmacy has been around company, the more satisfied customers they need to have. If you should be subsequent these ideas and use your good sense, you will most likely find a reliable pharmacy keep to purchase your prescription medications online an easy, rewarding experience. Ultimately, there are several properly recognized and experienced prescribed medications online stores are selling through their useful internet sites. For more information and facts, please do not wait to see their website ร้านขายยา ชลบุรี.
    1047 Posted by Sk office
  • All the individuals are involved to purchase prescription medications online from their comfortable home. With the development of internet engineering, the web shopping has been rising and so many individuals are thinking about shopping through the internet. You need to consider so many things before getting a reliable pharmacy keep in internet. When you're buying prescription medications online, you should workout some warning and do your study to ensure you get that which you spend for. These few lines will help you to discover a trustworthy online pharmacy. The initial position you have to search for is an detailed internet pharmaceutical. The absolute most reliable pharmacy pages have the ability to comprehensively tell visitors regarding their inventory, pricing, and paid off charge offers. They must be strong about showing people these features. If the costs and models appear inaccurate and obscure, do not trouble your self getting from the website. Reliable websites also provide detailed informative data on the recent medicine study and helpful recommendations on getting medicine online. There are numerous benefits to purchasing medications from online pharmacies. On the web pharmacy buys are most beneficial to seniors, handicapped persons, and citizens of rural towns. The seniors don't need certainly to worry about an exhausting journey to the neighborhood pharmacy. People of a long way away towns can only drop by the medicine keep web site and watch for their buy to be delivered. Apart from their ease, online pharmacies value medications at inexpensive costs. Individuals who need to save for operative procedures and other solution remedies can reduce rates by getting medications from the web. As opposed to regional pharmacies, pharmacy websites also provide detailed facts concerning the medications they are supplying. As you ]browse the internet site, every accessible solution involves a thorough account. This feature is certainly helpful for these under maintaining treatment. To start with, when you are buying prescription medications online, you will need contemplate that they need to have certification. Something we need remembers that trustworthy online pharmacies around the globe must present a valid international pharmacy association certification. This will assure the pharmacy meets all international rules and laws. The following items to contemplate that check evaluation sites. Now, the net will help you, see what other folks assert in regards to the pharmacy you intend to purchase from. Always get evaluations with a grain of salt, but usually if the web pharmacy has a lot of positive reviews, you may even have a good experience getting from them. After that you'll require to look for their receptive methods. Chances are if your true individual reacts to the web pharmacy email, or they have a stay support chat, you can get greater company as it shows which they worry about their customers. Discover the web pharmacy's contact data and give them a call or deliver them an email along with your questions. And you also need to test that do they need your doctor's membership or not. Dependable prescription medications online stores will need that you've a valid prescription for the medications your seed to buy. Please be sure that they need it for all medicine purchases. Ultimately, you will need to test that have they experienced company long. See the length of time this online pharmacy has been working for. And you also need to consider that shops they could be related with. The lengthier the pharmacy has been around company, the more satisfied customers they need to have. If you should be subsequent these ideas and use your good sense, you will most likely find a reliable pharmacy keep to purchase your prescription medications online an easy, rewarding experience. Ultimately, there are several properly recognized and experienced prescribed medications online stores are selling through their useful internet sites. For more information and facts, please do not wait to see their website ร้านขายยา ชลบุรี.
    Sep 29, 2018 1047
  • 10 Jul 2018
    Why is it so difficult for anyone who wish to find local transgenders for love? A common situation that we often caught our self facing in front of the mirror and repeatedly asking this question. I trust everyone to wonder know these things, lucky to find a guy who is interested in dating a trans woman. Darling you are not alone! There are millions of girls who are asking themselves at this very moment. There is nothing wrong with you in fact there is nothing to change about you. You just need to enhance a bit your aura to have a more positive outlook in life. And this positive attitude towards dating even trans dating online is very contagious and effective in meeting a guy! Now lets start enhancing that positive aura so we can find transgender love easily! First impression would last I believe this speaks for it self! We see his eyes or he see our red kissable lips. We see his dark brown hair and he sees that pinkish chick as we blush every time we get compliments. See we noticed our physical attributes first. I have some trivia for y’all, models are not perfect! Those photos that you see in the magazine and every where else comes with techniques and tricks! I am not talking about the photo shop, I’m talking about there angle! This may sound silly, try smiling in front of the mirror, keep that smile as you turn your face to your left and then right and see if there is a difference. I am sure there is! And that is what I call angle. You need to figure out which side you look best because as I have said first Impression would last! Most of us transsexual women loves to watch our self in front of the mirror so this is just a piece of cake. For the gentlemen there is now harm in trying. Heavy make up is not a big deal because when you find your good angle then it raps up everything. After all you want to present your self as natural as you can be, so there will be no surprises once you get to the point of meeting in person. I know this is a bit weird specially if it your first time. But as the saying goes. Practice makes it perfect. Nice and smooth conversation Okay this is common to us. We stutter and we lost of focus, ladies and gentlemen just keep it natural. When we are dating we sometimes struggle for words because we are too much conscious of how we look and how he or she see us. Now this is normal even superstars feels this. But you need to learn how to be relax, how to composed your self in a way that you feel comfortable with him/her. By having this you will be able to see your self in a good mood of conversing and exchanging word with your date. You will never have a problem of finding a question to asked. But just in case if you do, then be prepare with your back up plan. What’s the back up plan? Hey this is not an exam so stay cool. Asked about small things like “What did you do to your eyes?” they look amazing. Small talk that would lead to a compliment. And maybe you can make your conversation to the next level. Just spice it up a bit. You do not want to be the boring type of date that is surely unforgettable. Try throwing some sexy and naughty questions but not dirty. Like for example “lights on or lights off?” those sorts of topic that would suggest a tease but still decent. Please do not tend to lie just to keep up a good conversation and trying to create that you are meant for each other feeling. Saying no is not a bad thing on a date. It is in fact the purpose of getting to know each other. Being open yet respectful is a good way to make an interesting conversation that would make you want more. Create your new profile on ts dating site Only take few minutes and create your new profile on a ts dating site, this is so convenient and easy. Before it, learning some new tips about transgenders dating. Here we recommend a ts dating site: www.findlocaltransgenders.com
    808 Posted by Sk office
  • Why is it so difficult for anyone who wish to find local transgenders for love? A common situation that we often caught our self facing in front of the mirror and repeatedly asking this question. I trust everyone to wonder know these things, lucky to find a guy who is interested in dating a trans woman. Darling you are not alone! There are millions of girls who are asking themselves at this very moment. There is nothing wrong with you in fact there is nothing to change about you. You just need to enhance a bit your aura to have a more positive outlook in life. And this positive attitude towards dating even trans dating online is very contagious and effective in meeting a guy! Now lets start enhancing that positive aura so we can find transgender love easily! First impression would last I believe this speaks for it self! We see his eyes or he see our red kissable lips. We see his dark brown hair and he sees that pinkish chick as we blush every time we get compliments. See we noticed our physical attributes first. I have some trivia for y’all, models are not perfect! Those photos that you see in the magazine and every where else comes with techniques and tricks! I am not talking about the photo shop, I’m talking about there angle! This may sound silly, try smiling in front of the mirror, keep that smile as you turn your face to your left and then right and see if there is a difference. I am sure there is! And that is what I call angle. You need to figure out which side you look best because as I have said first Impression would last! Most of us transsexual women loves to watch our self in front of the mirror so this is just a piece of cake. For the gentlemen there is now harm in trying. Heavy make up is not a big deal because when you find your good angle then it raps up everything. After all you want to present your self as natural as you can be, so there will be no surprises once you get to the point of meeting in person. I know this is a bit weird specially if it your first time. But as the saying goes. Practice makes it perfect. Nice and smooth conversation Okay this is common to us. We stutter and we lost of focus, ladies and gentlemen just keep it natural. When we are dating we sometimes struggle for words because we are too much conscious of how we look and how he or she see us. Now this is normal even superstars feels this. But you need to learn how to be relax, how to composed your self in a way that you feel comfortable with him/her. By having this you will be able to see your self in a good mood of conversing and exchanging word with your date. You will never have a problem of finding a question to asked. But just in case if you do, then be prepare with your back up plan. What’s the back up plan? Hey this is not an exam so stay cool. Asked about small things like “What did you do to your eyes?” they look amazing. Small talk that would lead to a compliment. And maybe you can make your conversation to the next level. Just spice it up a bit. You do not want to be the boring type of date that is surely unforgettable. Try throwing some sexy and naughty questions but not dirty. Like for example “lights on or lights off?” those sorts of topic that would suggest a tease but still decent. Please do not tend to lie just to keep up a good conversation and trying to create that you are meant for each other feeling. Saying no is not a bad thing on a date. It is in fact the purpose of getting to know each other. Being open yet respectful is a good way to make an interesting conversation that would make you want more. Create your new profile on ts dating site Only take few minutes and create your new profile on a ts dating site, this is so convenient and easy. Before it, learning some new tips about transgenders dating. Here we recommend a ts dating site: www.findlocaltransgenders.com
    Jul 10, 2018 808
  • 14 May 2018
    AyurYoga Ashram is offering a 300-hour Yoga Teacher Training program nearby Mysure, India to teachers and students who have already completed 200 hours of yoga teacher training from a recognized school. Interested individuals can choose between the June 18 to July 16, 2018 and November 17 to December 15, 2018 schedules. Yoga teacher training India will deepen the participant’s understanding of advanced asanas, yoga nidras, kriyas, and pranayamas. This will improve not only their self-practice but also their ability to teach advanced sequences and poses. Those whose previous training doesn’t cover what’s considered standard syllabus may be asked to come for a 2-week intensive yoga course to prepare them for the advanced 300 hours yoga teacher training. Each class is composed of 20 to 30 students and a minimum 4 of 5 to teachers in a group. Those who are advanced enough to hold basic asanas for at least 1 minute are also qualified to join yoga Training India. The course is open to those with healthy back and joints as they have to practice 30 to 40 rounds of Sun Salutations daily. Participants should also have enough core strength to do 25 double leg lifts nonstop and a lung capacity enough sustain two 30-minute sessions of intensive pranayamas. Participants should have a basic understanding of the human body’s physiology and anatomy, stamina to handle lessons that last 10 hours a day and willingness to practice silence from 10 pm to 10 am. They should have no heart ailments, high blood pressure or chronic illness. Participants must be psychologically matured to deal with the group’s cultural differences. Advanced yoga teacher training will strengthen the participants’ joint core for advanced poses and improve their cardio-lung capacity so that they can breathe better. The course is taught by advanced teachers. Morning yoga classes focus on holding advanced and intermediate asanas longer to explore the body-breath-mind at a deeper level. Two pranayama sessions are held daily to help students master the basic pranayamas and teach them how to practice and teach advanced pranayamas safely. The training also includes daily practice of Kapalabhati/Bhastrika, Jala Neti, and Agnisara. Students who are ready will try out Prakshalana, Sutra Neti, and Shanka in the last week of training. AyurYoga’s 300-hour Yoga Teacher Training program also teaches various yoga nidra and meditation techniques that participants can teach to their future students. Participants will learn to read and write Sanskrit lessons. They will also be introduced to Ayurveda to help them understand the physical body and mind. Yoga therapy classes train students on contraindications of asans and how to deal with certain common diseases like asthma and high blood pressure. Students will learn how to chant Sanksrit prayers that they can use in classrooms. As for their teaching practice, each participant will be teaching at least 2 to 4 classes to a small group of 4 to 5 other students. They will also learn how to offer Chakra-based workshops. AyurYoga’s expert teachers will monitor these classes and help students with suggestions and corrections. Students will be continuously assessed throughout the program in 5 modules including self-practice, anatomy, and Ayurveda, teaching skills, the spirituality of yoga and philosophy and psychology of yoga. Students will be given one written examination of philosophy and anatomy to evaluate their understanding. Completing the course will give them a certification of RYT 300-hour teacher training, which will be added to their previous RYT 200 hours. This will qualify them as RYT 500 Hours with Yoga Alliance. About The Company Ayur Yoga Ashram India is a non-profit organization run by Krishna Chaitanya and other spiritual monks who want to help people incorporate yoga in their daily lives. The organization’s faculty is composed of at least six teachers, and many of them are recognized as ERYT 200 or E-RYT 500.  AyurYoga’s yoga teacher training certificate is valid for getting insurance and invoicing costs for further education and training for taxation purposes. For more information, visit https://www.ayuryoga-ashram.com/yoga-instructor-training-india/300-hour-advanced-yoga-teacher-training/ or call +1 (608) 319-1301 or +91 99866 99849. Media Contact Details +1 (608) 319-1301 +91 99866 99849 info@ayuryoga-ashram.com Company: AyurYoga Eco-Ashram Address: Village JP Hundi, Kannenur Post Hulhalli Hobli, Mysore District Karnataka, INDIA 571314 Email: info@ayuryoga-ashram.com Website: https://www.ayuryoga-ashram.com/spritual-retreats-india/ayurveda-course-certifications/      
    693 Posted by Sk office
  • AyurYoga Ashram is offering a 300-hour Yoga Teacher Training program nearby Mysure, India to teachers and students who have already completed 200 hours of yoga teacher training from a recognized school. Interested individuals can choose between the June 18 to July 16, 2018 and November 17 to December 15, 2018 schedules. Yoga teacher training India will deepen the participant’s understanding of advanced asanas, yoga nidras, kriyas, and pranayamas. This will improve not only their self-practice but also their ability to teach advanced sequences and poses. Those whose previous training doesn’t cover what’s considered standard syllabus may be asked to come for a 2-week intensive yoga course to prepare them for the advanced 300 hours yoga teacher training. Each class is composed of 20 to 30 students and a minimum 4 of 5 to teachers in a group. Those who are advanced enough to hold basic asanas for at least 1 minute are also qualified to join yoga Training India. The course is open to those with healthy back and joints as they have to practice 30 to 40 rounds of Sun Salutations daily. Participants should also have enough core strength to do 25 double leg lifts nonstop and a lung capacity enough sustain two 30-minute sessions of intensive pranayamas. Participants should have a basic understanding of the human body’s physiology and anatomy, stamina to handle lessons that last 10 hours a day and willingness to practice silence from 10 pm to 10 am. They should have no heart ailments, high blood pressure or chronic illness. Participants must be psychologically matured to deal with the group’s cultural differences. Advanced yoga teacher training will strengthen the participants’ joint core for advanced poses and improve their cardio-lung capacity so that they can breathe better. The course is taught by advanced teachers. Morning yoga classes focus on holding advanced and intermediate asanas longer to explore the body-breath-mind at a deeper level. Two pranayama sessions are held daily to help students master the basic pranayamas and teach them how to practice and teach advanced pranayamas safely. The training also includes daily practice of Kapalabhati/Bhastrika, Jala Neti, and Agnisara. Students who are ready will try out Prakshalana, Sutra Neti, and Shanka in the last week of training. AyurYoga’s 300-hour Yoga Teacher Training program also teaches various yoga nidra and meditation techniques that participants can teach to their future students. Participants will learn to read and write Sanskrit lessons. They will also be introduced to Ayurveda to help them understand the physical body and mind. Yoga therapy classes train students on contraindications of asans and how to deal with certain common diseases like asthma and high blood pressure. Students will learn how to chant Sanksrit prayers that they can use in classrooms. As for their teaching practice, each participant will be teaching at least 2 to 4 classes to a small group of 4 to 5 other students. They will also learn how to offer Chakra-based workshops. AyurYoga’s expert teachers will monitor these classes and help students with suggestions and corrections. Students will be continuously assessed throughout the program in 5 modules including self-practice, anatomy, and Ayurveda, teaching skills, the spirituality of yoga and philosophy and psychology of yoga. Students will be given one written examination of philosophy and anatomy to evaluate their understanding. Completing the course will give them a certification of RYT 300-hour teacher training, which will be added to their previous RYT 200 hours. This will qualify them as RYT 500 Hours with Yoga Alliance. About The Company Ayur Yoga Ashram India is a non-profit organization run by Krishna Chaitanya and other spiritual monks who want to help people incorporate yoga in their daily lives. The organization’s faculty is composed of at least six teachers, and many of them are recognized as ERYT 200 or E-RYT 500.  AyurYoga’s yoga teacher training certificate is valid for getting insurance and invoicing costs for further education and training for taxation purposes. For more information, visit https://www.ayuryoga-ashram.com/yoga-instructor-training-india/300-hour-advanced-yoga-teacher-training/ or call +1 (608) 319-1301 or +91 99866 99849. Media Contact Details +1 (608) 319-1301 +91 99866 99849 info@ayuryoga-ashram.com Company: AyurYoga Eco-Ashram Address: Village JP Hundi, Kannenur Post Hulhalli Hobli, Mysore District Karnataka, INDIA 571314 Email: info@ayuryoga-ashram.com Website: https://www.ayuryoga-ashram.com/spritual-retreats-india/ayurveda-course-certifications/      
    May 14, 2018 693
  • 09 May 2018
    Background: Phalloplasty with urethral lengthening is the procedure of choice for female-to-male transgender patients who desire an aesthetic phallus and standing micturition, but is associated with complications, including urethral stricture and fistula formation. Horizontal urethra construction can be accomplished with labia minora flaps covered with additional vascularized layers of vestibular tissue when vaginectomy is performed concomitantly with phalloplasty. However, vaginectomy is not a requisite step in phalloplasty, and some individuals may choose to retain their vagina. In these cases, extra layers of vascularized vestibular tissue are not used for horizontal urethra coverage. This study examined the effects of vaginectomy and the addition of extra layers of vascularized vestibular tissue on phalloplasty complication rates. Methods: A single-center retrospective study of 224 patients who underwent phalloplasty with urethral lengthening was performed. Patients were sorted into vaginectomy and vaginal preservation cohorts and complication rates were assessed. Results: Of 224 total phalloplasty patients, 215 underwent vaginectomy and nine underwent vaginal preservation. Urethral complications occurred in 27 percent of patients with vaginectomy and in 67 percent of patients with vaginal preservation (OR, 0.18; p = 0.02). Vaginectomy was associated with decreased urethral stricture (OR, 0.25; p = 0.047) and urethral fistula formation (OR, 0.13; p = 0.004). Non–urethra-related complications occurred in 15 percent of vaginectomy patients but were not statistically significant (OR, 3.37; p = 0.41). Conclusion: Vaginectomy is associated with a significant decrease in urethral stricture and fistula formation, most likely because vaginectomy affords additional horizontal urethroplasty suture line coverage of labia minora flaps with vascularized vestibular tissue. (Plast. Reconstr. Surg. 140: 551e, 2017.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III. Phalloplasty is one of the primary reconstructive options available to female to male transgender patients seeking female-to-male genderconfirming surgery. Regardless of reconstructive technique, the goals of phalloplasty include creating an aesthetic neophallus with tactile and erogenous sensation, allowing penetrative intercourse, and enabling micturition while standing.1 The latter is often a priority for transgender men,2 which requires phalloplasty to include urethral lengthening from local or distant tissues.3 Phalloplasty has very high satisfaction rates1; however, it can present several well-documented challenges to the reconstructive surgeon.4,5 Specifically, urethral strictures and fistulas occur with complication rates quoted at 30 percent, and as high as over 50 percent.1,4,6,7 Urethral complications are often a result of mechanical stress on From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center; the Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine; and Brownstein and Crane Surgical Services. Received for publication December 29, 2016; accepted April 5, 2017. Disclosure: The authors have no financial disclosures to declare and there was no funding obtained for the production of this article
    742 Posted by Sk office
  • Background: Phalloplasty with urethral lengthening is the procedure of choice for female-to-male transgender patients who desire an aesthetic phallus and standing micturition, but is associated with complications, including urethral stricture and fistula formation. Horizontal urethra construction can be accomplished with labia minora flaps covered with additional vascularized layers of vestibular tissue when vaginectomy is performed concomitantly with phalloplasty. However, vaginectomy is not a requisite step in phalloplasty, and some individuals may choose to retain their vagina. In these cases, extra layers of vascularized vestibular tissue are not used for horizontal urethra coverage. This study examined the effects of vaginectomy and the addition of extra layers of vascularized vestibular tissue on phalloplasty complication rates. Methods: A single-center retrospective study of 224 patients who underwent phalloplasty with urethral lengthening was performed. Patients were sorted into vaginectomy and vaginal preservation cohorts and complication rates were assessed. Results: Of 224 total phalloplasty patients, 215 underwent vaginectomy and nine underwent vaginal preservation. Urethral complications occurred in 27 percent of patients with vaginectomy and in 67 percent of patients with vaginal preservation (OR, 0.18; p = 0.02). Vaginectomy was associated with decreased urethral stricture (OR, 0.25; p = 0.047) and urethral fistula formation (OR, 0.13; p = 0.004). Non–urethra-related complications occurred in 15 percent of vaginectomy patients but were not statistically significant (OR, 3.37; p = 0.41). Conclusion: Vaginectomy is associated with a significant decrease in urethral stricture and fistula formation, most likely because vaginectomy affords additional horizontal urethroplasty suture line coverage of labia minora flaps with vascularized vestibular tissue. (Plast. Reconstr. Surg. 140: 551e, 2017.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III. Phalloplasty is one of the primary reconstructive options available to female to male transgender patients seeking female-to-male genderconfirming surgery. Regardless of reconstructive technique, the goals of phalloplasty include creating an aesthetic neophallus with tactile and erogenous sensation, allowing penetrative intercourse, and enabling micturition while standing.1 The latter is often a priority for transgender men,2 which requires phalloplasty to include urethral lengthening from local or distant tissues.3 Phalloplasty has very high satisfaction rates1; however, it can present several well-documented challenges to the reconstructive surgeon.4,5 Specifically, urethral strictures and fistulas occur with complication rates quoted at 30 percent, and as high as over 50 percent.1,4,6,7 Urethral complications are often a result of mechanical stress on From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center; the Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine; and Brownstein and Crane Surgical Services. Received for publication December 29, 2016; accepted April 5, 2017. Disclosure: The authors have no financial disclosures to declare and there was no funding obtained for the production of this article
    May 09, 2018 742