SURGERY for Transsexual People (F2M)

This section will discuss some of the surgical procedures commonly undertaken by those who are diagnosed as "transsexuals." Some of these procedures were adapted from similar surgeries performed on intersexed individuals.

SRS means "Sex Reassignment Sugery," which is the more widely accepted terminology for the so-called "Sex Change Operation" in the United States. Some people prefer to call it "Sex Reconstructive Surgery," especially if it is being done on an intersexed patient.

GRS means "Gender Reassignment Surgery," which is the more commonly used terminology for so-called "Sex Change Operations" outside the United States. Some people prefer to say it stands for "Genital Reconstructive Surgery" instead. Another new term for this has also surfaced: Gender Confirmation Surgery, but is not yet in wide usage.

Either term is acceptable and correct.

CHEST or "Top" SURGERY

This goal of this operation is to give the F2M gender patient a natural looking "male" chest.

Bilateral Mastectomy - also called a "double incision" or "incision" method. Two incisions are made to remove the mammary tissue and fatty tissues to shape the chest to a more masculine profile. It is usually performed with nipple grafts, but not always. Some feel it gives a better overall contour to the chest and allows for proper nipple placement. This generally leaves more noticable scarring than the Keyhole Technique discussed below.

Inverted 'T' Anchor Incision - this is not common. It is a procedure that is usually done during breast reduction surgery not breast removal surgery. It requires an extra incision made from the horizontal incisions to the center of each areola, in an inverted or upside down T shape. This usually result in more scarring than the "double incision" or "keyhole" techniques and should not be done in the case of F2M chest surgery.

Keyhole Technique - Also called "Periaereolar" or "Subcutaneous Mastectomy." One must be an A cup or a small B to have this surgery. A half moon or 'U' shaped incision is made around the underside of the each areola is right along where the dark pigmented areola skin and regular skin meet. The insides of each breast is removed using surgical tools that separates the breast tissue and fatty tissue from the inside, allowing it to be pulled out though the small opening. The patient is then sewn up. Drains may be inserted or there may be no need for them. But if needed, they are inserted through openings under the arms area into the area where the breast tissue once was. It is important to wear a binder for quite while, the length is determined by the surgeon, so that the loose skin adheres well to the chest. It may be necessary for the patient to undergo a second revision surgery to tighten up the loose skin should it hang or pucker months post-op.

Keyhole Liposuction - Some surgeons offer only liposuction through a "keyhole incision" to remove the fatty tissue composition of the breasts. The mammary (glandular) tissue remains. It is usually cheaper than a mastectomy operation but also doesn't provide the best masculine contour and doesn't alter nipple placement.

One side effect which is somewhat more common among patients of African or Asian descent is the formation of "keloids" after surgery. Keloids are a reddish, raised formation of fibrous scar tissue caused by excessive tissue repair in response to trauma or surgical incision.

"Bottom" or "Lower" Surgeries

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.

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.

SCROTOPLASTY (Testicular Implants)

Formation of the scrotum (scrotoplasty) is done during the metaoidioplasty. Should the patient desire, prostheses for testicles could be placed at the time of the metaoidioplasty or at a later date. Since there is frequently only limited space for these prostheses, some surgeons 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.

PHALLOPLASTY

A phalloplasty is the construction of male external genitalia (phallus).

Locoregional flap - flaps of skin from the groin and the abdomen have been used for many years and are the predecessors of the state-of-the-art "free flap" phalloplasty. They allow only phallic volume and length. Sensation is not possible and it is a multi-stage process. These flaps offer less than optimal results.

Free or Arm Flap - preferred for the construction of male genitalia which allows one to urinate while standing, a phallus with an erogenous and protective sensation that allows intercourse and pleasing appearance.

It begins with a five to six hour procedure usually done by two surgical teams. Forearm skin from the patient's non-dominant arm, along with sensory nervers, veins, and arteries, is taken to construct the urethra, glans, and penile shaft. The vaginal cavity is obstructed, and the labia majora are used to construct a scrotum. The nerves responsible for clitoral sensation are preserved and after being connected gradually grow into the neo-penis.

The penis is then attached by connecting the two urethras, clitoral nerves, and the arteries and veins to the groin area.

When protective sensation of the penis has recovered, approximately 9 monts after the first stage, testicular implants and implants to obtain regidity of the penis during erection on demand are inserted.

COST:

Costs for the cosmetic procedures like chest surgery are usually a few thousand dollars. F2M SRS procedures are considered much more difficult and less likely to yield satisfactory results. Becuase of the difficulty involved in Phalloplasty prices range from widely from about $20,000 up to $100,000. Generally SRS overseas is less expensive than within the United States. However, one must also factor in travel expenditures if seeking SRS overseas. Doctors in Asia tend to be less concerned with checking for "letters of recommendation" from a psychotherapist. Psychotherapy is not prevelent in most of Asia, which does not follow the HBIGDA Standards of Care, so it is a popular destination for those who seek SRS outside of the established medical guidelines in the West. Others go simply because it is less expensive and they get to turn their recovery into a tropical "vacation" or sorts. Those seeking surgery overseas should be aware that many government agencies in the United States will require a notorized letter from their surgeon in order to change legal documents (such as a US Passport or birth certificate). This can be problematic if one undergoes surgery in a country without a notary system. Those seeing foreign doctors should check with various State and Federal agencies ahead of time to find out what documentation they require or deem acceptable.

SURGEONS:

The following doctors who perform various FTM surgical procedures:

Dr. Gary Alter, Los Angeles, California, USA - Chest surgery, Metaidoioplasty, Secondary Reconstruction, Chin implants, rhinoplasty, and liposuction are among the procedures to improve appearance.

Dr. Prabhat Ahluwalia 140 Burwell Street, Suite 1, Little Falls, NY 13365 (315) 823-1111 - Hysterectomy.

Dr. Jeffery H. Aldrich, M.D., PH.D., F.A.C.S. ,Plastic Surgery Associates, Ltd., 385 N. Lexington Pkwy ,St. Paul, MN 55104. Phone: 612.645.3966 - Chest surgery

Fernando J. Bianco C., MD, Ph.D, PO Box: Apartado: 686, 36 Altamira, Caracas 1062, Venezuela - Chest surgery.

Stanley Biber, Trinidad, Colorado - Chest surgery and Phalloplasty. Stanley Biber reportedly does a decent chest job, but is not the greatest at phalloplasty. Biber considers his phalloplasty "experimental" surgery, but will still perform the procedure. Contact info: 406 First National Bank Building, Trinidad, Colorado 81082. Phone: (719) 846-3301

Dr. Robert Brannon, Dallas, Texas, USA. Phone: 214-368-3232 - Hysterectomy

Michael Brownstein of San Francisco, California USA - Chest surgery. Brownstein reportedly does the beautiful chest work. His most common technique is double incision, though recently he has been using a variety of techniques (including keyhole and laser tissue removal). The nipples are resized, grafted and repositioned. The scarring is reportedly very minimal and in most cases seem to fade to virtually nothing. He probably has the most experience in FTM chest reconstruction. His staff is reputed to be well informed and sensitive to the special concerns and sensitivities of transgendered men. Brownstein makes his primary incision below the breast line in a place that ends up falling right along the natural 'shadow' of the pecs. Beneath the nipple graft he places another layer of excess areola tissue, so that if a corner of the graft is lost, the skin underneath will grow forward and it will be the same color, etc. His patients say he is VERY versatile and willing to work with them to end up with the best possible results.

Peggy Ching MD, 2000 Van Ness suite 603, San Francisco, CA 94109. Phone (415)292-5678 - Chest surgery. She does the surgery in her office. She specializes in breast surgery including: reconstruction and gynocomastia.

Dr. Paul Costas, John Cuming Building, Suite 700, Concord, MA 01742. Phone: (508) 369-1579 - Chest surgery. He reportedly works with patients to find the best method for the patient’s body size, shape and desired end result.

Dr. Paul-J. Daverio, Chirurgie Plastique et Reconstructive, 10. Av. Saypie 1003 Lausanne, Switzerland - Phalloplasty (arm flap microsurgical).

Edwin Falces, MD, San Francisco, California, USA. Phone: 415-673-3940. - Chest surgery. Reportedly Decent chest reconstruction. Leans towards keyhole procedure only, but still does double incision.

Dr. Beverly Fischer, Aesthetic Institute of Maryland 2 Colgate Dr Suite 101, Forest Hill, MD, 21050. Phone: 410-561-3555 - Chest surgery (keyhole and double incision techniques).

Lawrence Foster, MD, Lake Tahoe, California, USA. Phone: 916-541-3355 - Chest surgery.

David A. Gilbert, MD, Suite 300, 400 West Brambleton Avenue, Norfolk, VA 23510. Phone: 1-800-999-9015 - Chest surgery and Phalloplasty. Gilbert reportedly does a moderate job on chests. He uses the t-incision which leaves an unnecessary scar coming down from the nipple. Gilbert does the forearm flap technique for the phalloplasty which leaves an unsightly and impossible to hide scar on the forearm. The final results of this surgery leave much to be desired. The penis and scrotum are made from the forearm skin and are the same color as that skin. It reportedly looks like it is constructed and barely resembles a penis and scrotum. One report says that when he commented at one of the conferences that the results were reasonable a couple of people responded that this was so if (1) you were half blind and (2) if you were 400 yards away. Also it is extremely expensive starting at $50,000.00. He also prefers that people do ALL surgeries with him--chest and genital reconstruction. Another possible downside, is that Gilbert requires a vaginectomy. It's been reported that he's said that a non-closed vaginal opening indicates that the person is just a "chick with a dick". He appears to have very rigid ideas about gender. Although the scarring is significant, he is considered by many to be the best in the Country (if not the world) on microsurgical phalloplasty technique(s) and trying to make the tissues sensate and "usable."

Louis J. Gooren, MD, AZVU PO Box 7057 1007 MB Amsterdam, The Netherlands - Chest surgery (keyhole technique).

Lawrence J. Gottlieb, M.D., Dept of Surgery University of Chicago, Chicago, Illinois 60637. Phone (312) 702-6302 (F2M only) or 312-962-6302. - Phalloplasty (microsurgery, forearm flap). This surgeon apparently has a terrible reputation for "mutilating" and disfiguring people.

Dr. Daniel Greenwald, 505 South Blvd., Tampa, FL 33606. Phone: (813) 258-2425 - Chest surgery and Phalloplasty (microsurgical, forearm flap technique).

Peter Haertsch, Sydney, Australia - Chest surgery. Breast reduction/chest reconstruction costs plus anesthetist's fee and two days hospital care total about $3500 Australian (approximately $2700 US).

Charles Horton, MD, Charles Horton, Jr, MD, Phone: 804-623-7072 - Phalloplasty. Reportedly they are former partners with David Gilbert (mentioned above).  Microvascular, forearm free-flap starts at $70,000.

Armand Hotimsky, Amsterdam, The Netherlands (no contact info) - Reportedly beautiful chest reconstruction.

Patrick Hudson, New Mexico, USA contact: doctor@phudson.com - Chest surgery.

Donald R. Laub, Stanford University Medical School. Plastic Surgery Center, 1515 El Camino Real, Palo Alto, California 94306. Office: (415) 327-7163, talk to Judy at 415-326-4645 - Double incision chest surgery, Metaoidioplasty, and Phalloplasty. Donald Laub allegedly does a mediocre chest job in that he leaves a fairly large scar and shaves off the nipples to resize them (which results in a large discolored blotch). His chests are reportedly not very natural looking. He was considered the best in the past for phalloplasty but apparently tends to be inconsistent in his results. He is the "expert" and the "founder" of the clitoral free-up/metaoidioplasty technique. Most metaoidioplasties reportedly have great appearance and sensation.

Dr. Laub Jr., 3 Timberland, South Burlington, VT 05403 Phone: 802-860-3340 - Double incision chest surgery and Metaoidioplasty.

Toby Meltzer, MD, Portland, Oregon, USA - Chest surgery, Phalloplasty (pedical flap only), testicular implants, and Metaoidioplasty. Reportedly does g reat chest jobs with minimal scarring and good positioning of nipples. Has a good track record for phalloplasties and clitoral free-ups. Considered by many to be the best US or Canadian surgeon doing metaoidioplasties. His primary area was not SRS but reconstructive surgery for accident and burn survivors. He takes intense pride in his work and is reportedly very fair with an excellent bedside manner. He is currently ONLY working with transgendered clients and only doing SRS surgeries. He offers patients a lot of versatility and choice in their health care/surgical options. He appears to be willing to work with patients to give them the results they most want – if surgically possible.

Yvon Menard, M.D., Montreal, Canada - Chest surgery, Phalloplasty, and Metaoidioplasty. Chest surgical results are reportedly mediocre. He is considered the leading keyhole technique surgeon in the North American continent – and the cheapest. The results are allegedly poor, unless the patient is VERY small chested prior to surgery. He uses a two stage technique, the first to remove the tissue, the second to resize the nipples/areolas and take up the excess skin with almost no visible scarring. Phalloplasty method used is the forearm flap. Menard has performed less than 12 phalloplasties. The scarring was reportedly excessive, on the forearm, leg and genital area, resulting in a rather malformed penis. He is alleged to have the highest rate of fistulas and strictures (and infection). Every patient reportedly has had to have follow-up surgery, usually for strictures or fistulas, or necrosis.

Mary Lee Peters, 1229 E. Madison, Arnold Pavillion, 15th floor, Seattle WA 98104 Phone: 206/292-6550 - Chest surgery. She is reputed to be a talented plastic surgeon. She's done a number of FTM chest surgeries and she does both keyhole and double incision and reportedly contours the chest nicely. Cost is about $5700 – everything included.

Dr. Renee Bennet O'Sullivan, 14 Denton Road, Wellesley, MA 02181 Phone: (617) 235-1007 - Chest surgery (keyhole technique only). She has apparently become a popular chest surgeon amongst FTMs, especially those who are small-chested. The results are reportedly quite adequate. She believes that any sized chest is suitable for keyhole technique. Her technique supposedly leaves a great amount of residual tissue, and she does not remove the mammary tissue.

Dr. Peter Raphael, M.D., Plastic & Reconstructive Surgery, 1600 Coit Road, Suite 105, Plano, Texas 75075 Phone: 972-985-0434 - Chest surgery, Metaoidioplasty, Testicular implants. Allegedly a very caring man. He has his own surgical center, which keeps the costs reasonable. His whole staff is reportedly very supportive.

James J. Reardon, MD, 737 Park Avenue, New York, NY 10021 Phone: (212) 832-0770 - Chest surgery. Reportedly has a pleasant demeanor, and good,predictable surgical results. Generally prefers double incision, though will use keyhole on requesting individuals who he believes will be good candidates.

Dr. Joseph Rosen, Dartmouth Medical Center, Dartmouth, New Hampshire, USA Phone:(603) 650-8068 - Chest surgery and Metaoidioplasty.

Dr. Michel Seghers, Burssels, Belgium - Chest surgery (keyhole technique), Hysterectomy, and Oophrectomy operations. Contact info: Avenue de Broqueville 60 1200 Brussels, Belgium Office: +32-2/ 770.01.08 Fax: +32-2/ 770.01.08 Department in hospital: +32-2/ 739.84.05

Dr. Kenneth L. Stein, 414 N. Orleans, Suite 209, Chicago, IL 60610 Phone: (312) 828-0060 - Chest surgery. Reportedly good results, though usually after several revisions. He is alleged to work well with patients to find the best technique that will yield the best results and is caring and sensitive.

Dr. Morton Slutsky, Atlanta, Georgia, USA (no contact info) - Chest surgery. Apparently specializes in larger breasted FTMs (and genetic women). Reportedly inconsistent results and "blotchy" nipples.

P. James Voloshin, MD, FRCS, 360 San Miguel, Suite 406, Newport Beach, CA 92660 Phone: 714/759-0627
E-mail: jimvol@ix.netcom.com - Chest surgery.

Dr. Weiss, Evans Medical Group, 720 Harrison Ave., Boston, MA 02118 Phone: (617) 638-8131 or (617) 638-8047 - Hysterectomy operations.

Neal Wilson, MD, 3011 W. Grand Blvd., Detroit, MI 48202 Phone: 313-874-5735 or 313-874-4197 - Chest surgery and Phalloplasty. No brouchure or literature is currently available. Does not give a price estimate over the phone but apparently his prices for chest reconstruction are based on breast size. He is reportedly becoming a popular FTM phalloplasty surgeon, although he allegedly does not have a very good reputation in some circles. His phalloplasty costs are reportedly less than many other phalloplastic surgeons in the United States.