Sexual Reassignment Surgery (Sex Change Operation)

Male to Female (MTF) Gender Reassignment Surgery (GRS) - Sex Change Surgery
The goal of transsexual surgery (sex change surgery) is to provide an aesthetically attractive and functional result which permits both effortless intromission and full orgasmic potential. Creation of an adequate vaginal pouch, a sensate and hooded clitoris, and a feminine vulva with delicate labia are paramount. Ultimate conjugation of the labial axis to the anterior midline (fourchette or commissure) requires a second stage procedure called a labiaplasty. To maintain and extend vaginal depth, medical grade dildos will be worn for a portion of each day. After suitable wound healing, sexual activity is a natural way to establish the permanency of the result.

Orchiectomy Procedure
The Orchiectomy Procedure is an independent procedure that can be performed for those who wish to eliminate testosterone surge and achieve some degree of secondary feminization without complete penectomy and vaginoplasty.

As this is an irreversible procedure, 2 letters of therapy clearance are required. One therapist (psychologist, psychiatrist, social worker, sexologist) must have a doctoral degree, and one of the two therapists must know the patient for an extended period of time. Conceivably one of the two therapists can satisfy the requirements for a doctoral degree and knowing the patient for an extended period of time. Consideration may be given to sperm banking prior to orchiectomy.

Female to Male (FTM) Gender Reassignment Surgery (GRS) - Sex Change Surgery
- Metoidioplasty
- Penile Implantation for the Neo-Phallus patient
- Insertion of Testicular Implants into Labia

A. Metoidioplasty or Metaidoioplasty (phallic clitoral enlargement, stand to void) - Sex Change Surgery
The procedure confers the advantage of minimal surgery with preservation of natural sensation and erectile function. Donor site forearm scars avoided. Overweight patients may achieve greater length with pubic lipectomy which will recess the body surface line.

In this sex change procedure the clitoral hood is lifted and the suspensory ligament of the clitoris is detached from the pubic bone, allowing the clitoris to extend out further. When the female tissues have been primed with testosterone, the clitoral head may resemble an adolescent glans penis. An embryonic urethral plate must be teased away from the underside of the clitoris to permit outward extension and a visible erection.

For those patients who desire to void standing after this sex change proceedure, the urethra is extended into the neo-penis. This may be accomplished simultaneously or performed secondarily using either a vaginal flap or buccal mucosal graft.

Please understand in that metoidioplasty (sex change surgery) involves a fair amount of tissue transfer, some degree of post-operative swelling is expected. Complications may include but are not limited to less than anticipated length, torquing of the clitoris (usually amenable to release), loss of sensation, tissue necrosis, localized infection, persistent tenderness or hypersensitivity, transient or permanent narrowing of the vaginal opening which may render the vagina incapable of penile penetration, urethral narrowing, urethral obstruction, and urethral fistula (leakage of urine anywhere along the pathway of urethral extension). Between the first and second stages leading to urethral extension, voiding patterns and trajectory may be forwards or backwards and may splash wetting perineal, labial and vaginal skin.

B. Penile Implantation for the Neo-Phallus patient.
A penile prosthesis confers the wherewithal to penetrate which may be the defining moment for a successful conclusion to gender reassignment surgery. Clearly the intimacy of complete sexual contact is sought equally by patients and their partners.

C. Insertion of Testicular Implants into Labia.
This should be performed as a procedure unto itself or with urethral extension to minimize complications. To prepare the labia majora for implantation, a tissue expander may be employed for a few months. This also creates a more pleasing scrotal appearance.

Labiaplasty - (Labia Minora Reduction)
Labiaplasty is offered to women with excessive, redundant labia who suffer from unsightly contour lines and physical discomfort. Such women report pinching or chafing when sitting or walking, hindrance during intromission, and difficulty maintaining hygiene during menses or after defecation.

Overly pigmented and unattractive labia can be reduced with a V-plasty technique that converges freshened margins in a neat concealable line. Delicate, minimally reactive, self absorbing plastic surgery suture is employed.

Pre--operative expectations are discussed in a relaxed environment. Reassurance regarding normal variation is provided. Areas of intended excision are delineated for patient approval with hand held mirror.

Surgery can be performed on an outpatient basis. Sexual activity may be resumed in 6 weeks. Excessive clitoral hood tissue may also be trimmed during this procedure as requested and is covered by our comprehensive fee.

Breast Augmentation
Breasts are universally recognized as a symbol of nourishment, love, femininity and sexuality. Breast augmentation is the second most popular cosmetic procedure performed (following liposuction), about 254,000 cases per year in the United States.

Breast prostheses applicable for standard implantation are typically saline filled and those for reconstructive surgery may be cohesive silicone gel filled. Cohesive gel implants when cut on the laboratory bench maintain their shape and do not leak. Perhaps in a few years cohesive gel implants could be used without restriction.

Prostheses come in difference profiles and some are anatomical in shape, i.e. tear dropped, being fuller in the lower pole.

The average expectancy of a saline filled breast prosthesis is about 16 years. However the likelihood that revisionary surgery will be performed within 5 years is about 25% across the board. The most common reasons for implant replacement are for request of size change 37%, leakage or rupture 24%, capsular contracture 18%.

Compare this with a 3% incidence of re operation in Dr. John Tebbetts series involving about 1662 patients with a 7 year followup. Careful matching of the implant to the unique anatomical features of the patient explains this.

Generally I subscribe to the Tebbetts formula for appropriate size. Oversizing creates many problems including early drooping (pendulous weight effect) and "double bubble." A distortion when the base of the implant below is seen distinctly from the base of the natural breast, above, which is of lesser circumference.

Breasts as they occur naturally are not perfectly symmetrical, "sisters not twins." Some balance can be achieved by differential filling and placement. Cleavage does not occur naturally and attempts to place implants so close as to achieve this may result in synmastia, the touching of one breast prosthesis against another.

The subpectoral approach is desired especially when pinched skin thickness is narrow in the upper pole (that breast tissue above the areola). This provides greater coverage of the implant. However, an implant is seldom entirely covered by the pectoralis muscle and is really bi-planar, partially sub-glandular in the lower outer quadrant where the pectoralis muscle is absent.

Athletes should avoid a subpectoral approach as it might impede pulling.

The two most popular in incisions are inframammary and periareolar. Other procedures include transaxillary (through the arm pit) or transumbilical.

The early detection of breast tumors may be slightly enhanced with prostheses although there may be some technical problems with compression during mammography.

Scarring can be minimized by taping over the incisional area for 3 months.

Massaging post implantation may reduce capsular contracture which can occur in 8 percent of patients, but can also result in some migration secondary to broadening of the pocket.

Anticipate a variable degree of pain for 3 or 4 days, associated with tissue stretching.

With respect to the ability to successfully breast feed after breast implantation, one study reported up to 64% of women with implants who were unable to breast feed compared to 7% without implants. The periareolar incision site may significantly reduce the ability to successfully breast feed.

Male Chest Reconstruction
Male Chest Reconstruction usually precedes below the waist surgery for FTM patients as protruding breast contours are a sin quo non of the female presentation.

While for very small breasts a peri-areolar skin excision can be performed, the problem of maintaining an adequate pedicle to support the nipple areolar complex without protrusion of the pedicle through the skin becomes challenging. Bringing skin into the borders of a contracted areola will cause puckering which hopefully with time will smooth out. A permanent fixation suture is often required to prevent tension on the suture line from causing a slowly expanding scar.

A transverse inframammary incision with free nipple areolar grafts is my preferred approach. If there is too much blousing of the skin, the alternatives are to extend the incision laterally (chasing a dog ear) or to make a vertical midline incision (inverted T).

The areola is trimmed to a pre agreed upon diameter and the nipple sectioned with a pie shaped excision and reconstituted.

Although the patient must be cautioned there may be varying sensory loss because of nerve disruption, our limited experience has been favorable in this regard as distal nerves are known to regenerate.

Nipple areolar grafts must be kept wet with saline soaked gauze re-moistened every 3 hours for at least 5 days to maintain tissue viability until capillary buds grow into the graft.

Plan on having a roommate or spouse do this for you throughout the night.

Some crusting of the grafts is not unusual and will usually shed by the 3 or 4th week. By all means do not lift or pick them off as the adherence of the graft may be very tenuous and its viability very fragile.

After tissue settling some revision surgery may be required and is usually done for a nominal fee relating only to use of the facility and anesthetic services if required (as opposed to being done under local).

Breast sizes greater than a C, need to be done in hospital setting.

Sex Change Operation Before and After Image (M-F)

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