FTM SRS
Overview
Dr. Meltzer is part of a gender dysphoria team that consist of a urologist, a gynecologist and a plastic surgeon. Our team adheres to the same guidelines and principles of the Harry Benjamin International Gender Dysphoria Association. Prior to any surgical procedure, the prospective patients must fulfill the criteria established by the Benjamin Society and have letters of referral from a therapist (psychiatrist, psychologist or psychiatric social worker) who has had a long-term relationship with the patient. Your therapist should have a copy of these standards or we can send you a copy.
Though not a prerequisite to other procedures, removal of the uterus and ovaries (hysterectomy and oopherectomy) are frequently performed. This can be done vaginally with laparoscopic assistance, or vaginally. The vagina can also be completely removed at the same time or as a separate procedure. A vaginectomy is only required if the urethra is to be lengthened to allow one to stand and urinate.
Expanded list of procedures
- Chest surgery
- Genital masculinization
- This is the least invasive procedure done. It is a modified metoidioplasty and does not involve any work done to the scrotum.
- Metoidioplasty
- Scrotoplasty
- Placement of testicular expanders
- Placement of permanent prosthesis
- Urethral lengthening
- Either as a primary procedure or using buccal mucosa. Dr. Mitchell Kaye (a urologist) works with Dr. Meltzer on these procedures.
- Hysterectomy/Oophorectomy/Vaginectomy
- Performed by Dr. Burt Webb
- Pedicle flap
- Glansoplasty
- Placement of erectile device
- Repair of previous surgeries done by other surgeons, i.e., fistulas, strictures, etc.
- Routine plastic surgery procedures: Liposuction, etc.
Lower surgery
Metoidioplasty
The most common genital operation that Dr. Meltzer performs for FTM patients is a Metoidioplasty. In this operation, the surrounding skin of the clitoris is removed and it is released from the pubis to give the appearance of more length. The glans will appear circumcised in most patients. The final result is a normal appearing, but very small, penis.
This is a very favorable result. Actual result will depend on various factors as described below.
The outcome is largely dependent upon how much enlargement of the clitoris has occurred with Testosterone. Urethral lengthening can also be done at the same time, or at a later time,to allow the patient to stand to urinate. Urethral lengthening requires complete removal of the vagina. The best results from the metoidioplasty are in patients who are thin or near their ideal body weight. In most patients, removal of the skin and fat of the mons pubis and pulling the skin upwards will improve the result. This will leave a curvilinear scar in the pubic hair and is usually done as a second stage when the expanders are replaced with a permanent testicular prosthesis.
The principal advantage of the metaoidioplasty is that it is noninvasive, maintains the sensitivity of the clitoris, and does not create apparent surgical scars. Furthermore, it does not prevent future genital surgery from being done at a later time should one decide. The penis will not, however, appear adult in size, and it is not large enough for vaginal intercourse. Formation of the scrotum (scrotoplasty) is done during the metaoidioplasty. Should you desire, prostheses for testicles could be placed at this time or at later date. Since there is frequently only limited space for these prostheses, I will often place two tissue expanders in the new scrotum. These are inflatable balloons placed in the scrotum, and then slowly inflated, at home, to expand the scrotal sack. Three to six months later, the permanent prosthesis can be placed in the expanded scrotum, with fewer problems. Although this method requires two operations, the end results are frequently better. The secondary procedure is an outpatient operation and the patient can return home the same day. There is probably no harm in placing two testicular prostheses, understanding that it may be necessary to lower one at a later time. If urethral lengthening is done, one must wait three months to have expanders or prosthesis placed.
Pedicle Flap
This procedure requires several stages. The first stage is the creation of a phallus by using skin harvested from either the flank area or the lower abdomen area and forming a tube. The principal advantage to this procedure is that it creates a penis of significant size and bulk that can accommodate an erectile device, thus allowing for penetration. The tube is left attached at its origin, and the free end is attached to the pubis. The result resembles a suitcase handle. The second stage is a procedure known as a "delay". The purpose of the "delay" is to improve the blood supply to the neo-penis. The first "delay" is done one month after the primary procedure. The patient may be instructed on how to use a temporary tourniquet around the base of the neo-penis to further enhance the blood supply. However, there are options and more than one "delay" may be necessary. At approximately three months, the flap is completely separated from its origin (either flank or abdomen), allowing the phallus to hang freely.
Six months or more after the original procedure, the patient can have the tip of the phallus sculpted to create the appearance of a glans. After a minimum of one year, an erectile device can be placed to allow penetration (intercourse). However, since the shaft of the penis is insensate, there is a greater risk of having the erectile device erode through the penile skin. Dr. Meltzer wraps the erectile device in a dacron sheath to reduce this risk.
ADVANTAGES OF THE PEDICLE FLAP Bulk and size of penis and can accommodate erectile device to allow for intercourse. Patient must be observant for signs of extrusion.
DISADVANTAGES OF THE PEDICLE FLAP Insensate penis. Urethral lengthening should be performed only with a full understanding of the high risk associated with the combined procedure. Risks such as strictures and urinary fistula (abnormal drainage of urine). Multiple trips to the surgeon's office may be required.
Chest surgery
The procedure is based on the following:
- Size and shape of breast
- Elasticity of skin
- Patient's needs and preferences
In general, patients who have smaller breasts can have the entire surgery performed through an incision in the lower half of areola (the pigmented portion of the nipple) using liposuction in combination with surgical removal. It is also possible to remove larger breasts using this technique, if the skin of the breast is thicker, more elastic, and not damaged or stretched out. In these patients with good skin tone, the excess skin and the areola will shrink a remarkable amount. If the skin does not shrink enough, it may be necessary to have a small amount of skin removed (in a keyhole pattern or in an incision around the areola). If the patient is willing to return for an additional procedure if necessary, I think this is a very reasonable approach. In those patients with a large amount of breast tissue with excessive skin of poor quality and droop, I usually recommend removing the excess skin and breast tissue in the crease of the pectoralis muscles and put the nipples back on as grafts. However, this surgery leaves larger scars on the chest.
Some small breasted patients have a strong preference for liposuction alone in order to preserve sensation or to stretch out the costs. You can have the liposuction done first, and if necessary, the residual breast tissue can be removed in a second operation. Having this done in two stages probably doesn't alter the final result, but does increase the number of operations required and time off work. In a majority of patients who have liposuction alone, Dr. Meltzer thinks he could improve the result with surgical excision of the remainder of the breast tissue. Nevertheless, this is his opinion, and some people are quite content with just liposuction.
Chest surgery is routinely done as an outpatient. The patient will need to stay in the area from three to six days following the surgery depending on the type of procedure done. However, if you live in the Scottsdale area you can be discharged home. Patients may also stay in nearby hotels. If a patient chooses to stay in a hotel they should have a friend or family member stay with them to help with their care.
Risks and complications
Obviously, procedures such as this are not without risks or complications and Dr. Meltzer wants to review these with you.
- Bleeding: Bleeding is a risk of any operation, but the need for transfusion is very unlikely. However, when using minimal incisions to surgically excise most of the breast tissue the risk of blood loss is greater. Although a transfusion has not been required to date using this combined approach, it is recommended that you consider donating a unit of your own blood in advance of surgery to assure that if a transfusion is necessary, the blood would be your own.
- Infection: Infections are rare complications.
- Nipple numbness: The blood supply of the nipple might be damaged with the more limited surgery, and the nipple could die. If the nipples are used as grafts, then it is possible that they might not survive. These complications are exceedingly rare in my experience.
- Scarring: The scars of the areola usually heal very well. The scars below the pectoral muscles will take longer to fade out and will widen as mentioned above; however, a raised or excessively wide scar is possible and might need further treatment. It is possible that there may be residual tissue left, which appears as a contour deformity. This would need to be removed at a second stage.
- Other risks: Depression of the skin where the breast tissue was removed is a risk and possible complication. The possibility of this complication can be reduced or avoided by leaving some breast tissue on the skin. Since not all the breast tissue is removed, you are still at risk for developing breast cancer, and therefore, you should still be vigilant in routine self-exam and screening for breast cancer.
Fees
Please contact our office for current fees at 1-866-876-6329 or 480-657-7006 or email Carole Barkley or Linda Takata.
Preoperative instructions
Once surgery is scheduled, a patient will receive a letter confirming both the date for the preoperative appointment and the surgery.
- Referral letters from the patient's therapists must be sent directly to our office at least three months before their surgery date.
- Please contact our patient care coordinator, Carole Barkley or Linda Takata via e-mail or by phone at 866-876-6329 or 480-657-7006 to schedule a consultation visit or surgery date with Dr. Meltzer.
- Medications: Unless otherwise directed by your physician, do not take any Aspirin, Vitamin-E, or non-steroidal anti-inflammatory (i.e.: Advil, Aleve, Ibuprofen) three weeks prior to your surgery, since this interferes with normal blood clotting. If you need a pain medication for general purposes, use Tylenol or if you are in doubt about any medications you are taking, please contact our office. Please see the attached list for products that contain Aspirin, Ibuprofen, or Vitamin E.
- If you are taking any medications on a regular basis, please let Dr. Meltzer know, especially if you are taking any cardiac or hypertensive medications (such as Beta-Blockers). If your are on several medications, please bring a list with dosage and type to the hospital with you.
- Take your regular medications as you normally would with a small sip of water, the day of surgery, unless otherwise instructed.
- Smoking significantly increases the risk of complications during and after surgery. Therefore, it is in your best interest to stop smoking as soon as possible but no less than one month before surgery. Our office will require you to sign and return our form about smoking.
- Please report any signs of a cold, infection or skin lesion anytime prior to your surgery.
- You may not have anything to eat or drink after midnight before your procedure. Please check with your physician. (Please notify your physician if you are diabetic or have any other concerns regarding this instruction.)
1. On the day of your discharge, please be prepared to have someone drive you or to take a cab. If you have had any prescription pain medication, you cannot drive. In addition, please make sure you will have someone at home to assist you.
Products containing aspirin
| Alka-Seltzer | Cope | Fiogesic | P-A-C |
| Anacin | Coricidin | Fiorgen | Percodan |
| Anexsia with Codeine | Damason | Fioricet | Presalin |
| Andynos | Darvon | Fiorinal | Robaxasil |
| Aspirin | Dristan | 4-Way Cold Tablet | Roxiprin |
| Aspirin suppositories | Dia-Gesic | Gemnisyn | Saleto |
| Ascriptin | Digel | Indocin | Salocol |
| Aspergum | Dolprin #3 tablets | Liquiprin | SK-65 Compound |
| Axotal | Donatab | Lortab | Sine-Aid |
| B-A-C | Doxaphene | Magnaprin | Sine-Off |
| Baby Aspirin | Duragesic | Marnal | St. Joseph |
| Bayer | Easprin | Meprobamate | Supac |
| BC Powder | Ecotrin | Midol | Talwin Compound |
| Bexophene | Emagrin Forte | Momentum | Trigesic |
| Buffaprin | Empirin | Norgesic | Tolectin |
| Bufferin | Emprazil | Norwich | Triaminicin |
| Buffinol | Equagesic | Orphengesic | Vanquish |
| Cama-Arthritis Strength | Equazine | Oxycodone | Zorprin |
| Congespirin | Excedrin | Pabalate | Zomax |
Products containing Ibuprofen
| Advil | Medipren | Midol 200 | Nuprin |
| Haltran | Midol | Motrin | Rufen |
Other products which promote bleeding
| Vitamin E | Marine Fatty Acids | Omega-3 Fish Oil Supplements |
A note on products that interfere with blood clotting
It is necessary to discontinue the use of any of these products as they may inhibit the normal blood coagulation mechanism and may cause excessive bleeding and bruising during or after the surgery.
If you are in doubt as to whether or not the medication you are taking will interfere with your surgery, please call your physician.
A note on smoking
Smoking can significantly affect the outcome of your procedure. Please be aware that the long term effects of smoking cause a narrowing of the small arterial blood vessels that traverse the skin. This decreases the circulation of the tissues of the skin and makes it necessary for the surgeon to be more conservative in any plastic surgery procedure. Smoking near the time of surgery causes a further acute narrowing of the blood vessels which may cause ischemia of the tissue, poor healing, bad scars, or actual loss of tissue. If you smoke, our office will require you to sign our form regarding smoking.
Questions
Please contact our office at 866-876-6329 or e-mail Carole Barkley or Linda Takata for current pricing and questions about scheduling.
Last modified: December 30, 2003 06:17 PM
Maintained by Linda Takata.
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All information © Toby R. Meltzer, MD PC, 1996-2004. Photographs provided are anonymous and also © Toby R. Meltzer, MD PC, 1996-2004.
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