#3 years post op phalloplasty

[answersfromzestual]

Another person out there! Answered a different way as well. And a similar but different procedure. It gives you options and I like how he mentioned his previous bladder conditions to help clarify more and show that maybe if you have the same issues they should consider the risks as he has.

I'm sure he wouldn't mind a follow?

The options are great, and I would say, actually, numerous.

I like to see other trans men post op posting and letting others know it's not scary, but definitely has some risks depending on your health.

Thanks @twinfools for your post!

I would love if you wanted to submit more about your journey choosing not to lengthen your urethra and why you chose phalloplasty? And anything else you feel like sharing would also be great!

Stay Golden Everyone ✌️ 💙 💜

I’m 3 years post phalloplasty and I realized I’ve never really made a post about how things are going. Phalloplasty is a hard surgery to talk about because, bottom line, it’s not part of common conversation to talk about yo dick. That being said I think it’s really important for me to talk about this procedure to help break stigma and misinformation— both inside and outside of trans and non-binary communities.

I had ALT phalloplasty, glansplasty, scrotoplasty, no urethral lengthening (UL) with vaginectomy. This means that tissue from my thigh was used to create my penis, my urethra was not extended or moved (so I don’t stand to pee) and my vagina was closed. I feel like this detail is important because this is one of many variations for this procedure and what I opted for/out of were decisions made according to trade-offs between personal benefit and risk.

I opted out of UL because I do not tolerate catheters well and, due to my very active lifestyle, was not willing to risk longer term catheterization or bladder spasms which would impede my quality of life. This risk, for me, outweighed the benefit of standing to pee.

I opted for ALT knowing that I would likely need debulking (which I didn’t end up needing but opted for anyway out of preference). Debulking is a procedure to make the penis less girthy as ALT phalloplasty is more girthy because of the nature of tissue on the thigh. I chose ALT because, first and foremost, I did not want scarring on my forearm. My ALT scar is covered by clothing most of the time which I appreciate. I also chose ALT because I have skinny forearms, which wasn’t ideal for forearm phalloplasty (RFF).

Vaginectomy, for me, was a no brainer. I have never used or connected with that part of my body so I wanted it gone.

Glansplasty is a procedure to make the glans (head) of the penis and was a short procedure done after my initial stage of surgery. I may get it redone but I’m still undecided on that. Scrotoplasty creates a scrotum, I was ambivalent about this procedure but have grown to more appreciate it over time.

I am considering further surgeries: erectile implant (which creates the ability for the penis to “get hard”) and testicular implants (fills to scrotum with testicle implants). But I’m undecided and want a break from surgery while I finish my degree and focus on work. I’m also considering phalloplasty tattooing to help enhance the contour and coloring to make it appear more like a cis penis.

Whew! Lots of info, right? These are big procedures completed over multiple stages and are very unlike chest surgery, hysterectomy and other surgeries I had completed prior. When I was first considering this surgery I didn’t know there was flexibility in terms of tissue donor site and UL. I waited to have this surgery and am so happy I did because the information I gained from research and consulting with professionals and folks with lived experience was so valuable.

Was surgery hard? Yes. This surgery was the hardest thing I’ve ever been through. I’ve never been so uncomfortable for the first 2 weeks after recovering. I had to re-learn how to walk. I couldn’t sleep. Peeing hurt… but would I do it again? Yes. It was worth it for me but I can’t underscore enough that that doesn’t mean I didn’t have moments where I felt regret while recovering because post op depression is a thing and I was in pain while adjusting to a new body part that was also a healing surgical site… LOTS going on there!

3 years on I feel really at home in my body. Just having a penis is such a comfort to me in ways I didn’t anticipate. I’ve had a feeling my entire life that I was missing a body part and this was it. The quiet gender euphoria of just sitting and feeling my body and for once feeling complete in that is something that’s hard to articulate.

I’m thankfully back to full mobility and got back to full mobility about 3 months post op. I was grateful for this since a long term recovery wasn’t what I wanted. There are still weird twitches, pains and feelings, especially around my donor site (thigh) from time to time but nothing that inhibits me. Just interesting when it happens (usually when weather gets colder?).

What is one thing I would want to go back and tell myself before surgery? Well:

Your penis will feel HEAVY. Like it will fall off. It won’t fall off and your body will adjust to the weight in an area you didn’t have it before. Until then it will feel like you need to hold it at all times.

Hopefully this helps someone as an overview of what an experience with this procedure may look like. Again, my goal is to put information out there and have frank conversations— because it’s these same things that greatly benefitted me in my surgery journey.

Finally— my inbox is open for anyone that has questions. I am in a privileged position to feel safe talking about these things and I feel comfortable doing so. Not everyone does, so please don’t assume that this invitation applies to other folks who have accessed surgery unless they say so.

Thank you for reading :)

[sanguinaryrot]

and irt the phalloplasty post when I said directly after surgery I mean people will look at a picture of phalloplasty 20 minutes after surgery, stitches, covered in blood, and reddened from irritation. And then be like THATS NOT WHAT CIS PENISES LOOK LIKE!!!! Like a) yeah. It’s not done yet. there is follow up surgeries and healing left. If you looked at 3 years post op with glandsplasty and/or scrotoplasty and/or medical tattooing it looks incredible and b) what happened to I don’t want to look or act cis? you sound like a dumbass and C) ITS NOT YOUR FUCKING BODY if a man wants a penis that is just a tube of flesh to alleviate dysphoria why the fuck are you talking about how he ruined his beautiful womanly perfectly functional body. Do you fucking hear yourself? Are you listening to the words you say?

[camerons-t-diary]

6/27/21

I have really been down on myself for so long for not keeping this blog up to date and not posting more recovery details as they were happening. Sometimes being in the middle of it is more overwhelming that you aren’t really thinking much about documenting it lol

That being said I am at a much better place in my life right now and am extremely motivated in a lot of areas. I am working full time, going to the gym 5 days a week, and training to become a fitness/nutrition coach. I really feel like I am in a spot to get this blog a lot more active and keep up with it on daily basis. I would really love to get more information out there and routinely be answering questions many of you might have.

I just recently passed my 4 years post op phalloplasty and am less than a week away from my 6 years post op for top surgery. I am also 10 months post op the 3 piece inflatable erectile implant and nearly 8 years on testosterone.

Please feel free to message me any topics you’d like me to make a more in depth post about! You can really ask me anything, but if I feel like the question is too far then I will just say so instead of answering!

[answersfromzestual]

Second Part of Directory

Egg Harvesting Procedure and cryogenic preservation.

Phalloplasty and Metoidioplasty Side by Side Comparison

PhalloplastyProcedure full outline offical - Article

My Chest after 15 years+ Post-Op

How does pumping to get erect affect spontaneous intimacy sessions- Ask

Male and Female Genitalia, what does it look like and how does it work? - Detailed information and image with labels.

Sexually Transmitted Infections/Diseases Information- description, symptoms,and treatments included.

Abdominal Phalloplasty Summary with Q&A

3 Ways to Deepen and Darken your Vocals - FtM Vocal Training Tips (YouTube Video by Jordan Ross)

Navigating dating when you are heterosexual and Transitioning

Bottom Growth on testosterone (T-phallus) information - ask

Will being on Testerone Hormone Replacement Therapy Lead to Osteoporosis? - Answered Question

Dear Readers, make sure to check in about once a week to see if any new relevant information may has been added!

https://www.tumblr.com/answersfromzestual/750260985732972544?source=share

Improved Blog Directory - Find what you need

BLOG RULES: PLEASE READ

Educational Article on the Phalloplasty Surgical Procedure -self written

How to choose clothing/shoe sizes during transition - clothing on smaller feet and frames

Formal Wear - how to dress formally during transition.

Need to speak to someone? Do you need help with your legal name change? Please click here. Translifeline.org

USA Safe States for Trans-People (Constantly Updated by the website Owner)

What to Update After Legal Name Change

Hormone Replacement Therapy (HRT) Testosterone - storage, travel, and injection advice

Facial Hair Information- Tips and Tricks on How to Shave (HRT)

Frequently Asked Questions about Phalloplasty - My [personal] Experiences

How can one ejaculate after phalloplasty procedure? -ask answered.

Common Phalloplasty Misconceptions- Article

Male Mannerisms- help to know male gestures, wording, and attitude- (ask)

Beginning testosterone, testosterone hormone therapy

Testosterone Experiences That Caught Me Off Guard - (Ask)

Safe Binding and Packing - Articles Purchase Sites Also

Staying Stealth During Surgeries, Explaing Scarring - advice (ask)

Top Surgery (both ftm & mtf), procedures, and approximate costs.

Can I have top surgery and be overweight?

Keyhole Top Surgery Procdure- Outline and what qualifies you as a potential candidate

Finding a Top Surgeron in North America

So You Just Had Surgery (Top)- Advice on the best way to heal after surgery/ minimize scarring.

Is more time on the operating table really better? Operating time and infection information.

Metoidioplasty FAQ

My arm and upper thigh after about a decade after phalloplasty.

My Personal Surgeon and Their Clinic

Interview with Dr. Chen about Bottom Surgery

Penile/ Phalloplasty Erectile Devices

Expectations- Personal Advice on Setting Expectations

Urethra lengthening Procedure Information- Self written article.

Importance of Uriologist

Phalloplasty Website - Includes Parents Guide

Urethra Lengthening Procedure

General Surgical Risks

Plus Sized Surgery Risks

List of Phalloplasty Surgerons in the USA

Vaginal-Perservering Phalloplasty Procedure

Graft SiteCare for Forearm -Free Flap Phalloplasty

What Happens if Erectile Device Breaks?

Image of My Phalloplasty (wearing underwear) Educational Purposes Only

Phalloplasty Procedure Outline by GRS Montreal - (Link to Webpage)

First Every Phalloplasty Procedure - Surgeon

Michael Dillon- Trans Pioneer (First phalloplasty patient)

How to Find Proper Sources of Information in a World of False Information/ Online Safety

Why certain terms can be hurtful. Please respect my/others views.

Tattooing over your forearm skin graft -ask

Testosterone and Hair Loss Information

If there are any other posts/ other topics I should add to this directory, please send me an ask. I will never post your username without your expressed consent in the ask.

[transgenderteensurvivalguide]

July 2021 marks the one year anniversary of 'ALT Dick Story Share' monthly Zoom group.

As a way to celebrate, there will be a special event: a Zoom panel discussion, with a diverse group of post-op ALT folks sharing their experiences.

NOTE: This event's Zoom will be different than their usual monthly Zoom link, so even if you have been to their ZOOM meetings before, to receive the Zoom link for this event you MUST pre-register: bit.ly/altphallo

WHEN:

JUL 25 (SUN)

3-4:30pm EST / 2-3:30pm CST / 12-1:30pm PST

[***IMPORTANT*** please log on time, the event will be closed after 15min]

Feel free to share this flyer/info with folks who are considering ALT phalloplasty!

Register here:

https://docs.google.com/forms/d/e/1FAIpQLSc0iPRrwBPB8mQFT3yK9chYqIyLVadDtWmIVlqBwwq0rcmEOw/viewform

[loadingluke]

Today I’m one year post stage 1 phalloplasty. I was going to make a long post breaking down everything I’ve gone through in the last year, all about my recovery and the physical stuff, but I think I’ll leave that for later when I’m more recovered from stage 3 and I’m better prepared. But I did want to take a moment to talk a little about the mental impact that this year and this surgery has had on me.

This year has been one of the most challenging and rewarding years of my life. A lot of sacrifice, pain, and years of preperation has resulted in what is and will continue to be a peace and comfort I didn’t know was possible. This surgery has been the best decision I’ve ever made. I have been given the ability to actually function, and I am now able to actually work towards becoming the person I know I can be. I know I’m now able to actually work towards my goals without the fog that was daily debilitating dysphoria and hopelessness that got in the way. Even though it took a lot of work and heartache, money and time on hold to get here I’d do it again in a heartbeat.

I want to thank all the health care professionals who have made this possible for me, all my doctors and nurses and OTs especially Dr Goossen and Dr Ingram.

I want to thank everyone else who is brave enough to share their experiences online and this community we are building- knowing this isn’t something I have to go through alone has been very comforting and I’m glad to call you my friends.

I want to thank my family and friends, especially my mum who stayed with me during stage 1 and 2, the and my friends who have opened their home to me for months while I recover.

And of course, my wonderful partner, who has been my bloody rock for the last 4 years, but especially this year. I don’t know how I would have coped without her at my side throughout this entire process and I love her dearly.

This surgery isn’t something that happens overnight, and it’s not something that one can just get over and done with on your own. I guess it takes a village to make a penis (I thought this was clever but I think it sounds kinda weird but the point still stands so I’m keeping it in!).

If this is something you are planning or actively pursuing, know you aren’t alone and there are tons of people in the same boat here with you, and many people around who will help you get there. It might feel forever away and trust me I know how much it sucks but the wait is worth it. I really hope that whoever you are you are able to experience peace in your body, surgical intervention required or not, and I wish you the best of luck on all your endeavours.

Happy 1 year post op to me and here is to the rest of my life with this body I’ll be forever grateful for ❤️

[realtransfacts]

Transmasc Lower Surgery Masterpost

Note: Not everyone who wants these surgeries identifies as transmasculine, nor does every transmasculine person want these surgeries.

& if anyone else has any other good resources you want to share, please do feel free to add to this post! <3

Metoidioplasty:

How Metoidioplasty Works [Animation] Video

One Year Post Metoidioplasty Video

Healthline: Metoidioplasty

What is Metoidioplasty: Overview, Benefits, and Expected Results

Trans 101: Ep 25 - Metoidioplasty Video

Metoidioplasty FAQ

Why I Had Metoidioplasty Over Phalloplasty Video

Transgender 101: Metoidioplasty

Metoidioplasty Blogs

Metoidioplasty Risks and Complications

1 year post-op! + new dick pics

Metoidioplasty Q&A

Metoidioplasty Wiki

Phalloplasty:

Phalloplasty: Gender Confirmation Surgery

Trans 101: Ep 26 - Phalloplasty Video

Why Did I Choose Phallo Over Meta Video

Phalloplasty FAQ

Phalloplasty Seeing My Arm For The First Time Video

What Does a Skin Graft Feel Like? Video

Phalloplasty Risks and Complications

Lower Surgery Q & A

Phalloplasty Things I Wish I Would Have Prepared For Video

The Total Guide to Penile Implants

Phalloplasty: Frequently Asked Questions

Phalloplasty Q&A Video

Phalloplasty Wiki

Phalloplasty without vaginectomy?

Scrotoplasty:

Scrotoplasty and Testicular Implants

Scrotoplasty: Testicle Implants

Scrotoplasty Wiki

Post-phallo/scrotoplasty guys: How sensitive are your balls?

Vaginectomy:

Vaginectomy: What Trans Men Need to Know

Vaginectomy: Critical Info for Trans Men

Vaginectomy Wiki

General:

Genital Reconstruction Surgery

The Difference Between a Metoidioplasty and a Phalloplasty

Preparing for Bottom Surgery Video

Phalloplasty and metoidioplasty - overview and postoperative considerations

Masculinizing surgery

Bottom Surgery posts

Bottom Surgery: What You Need to Know

Transmasculine Bottom Surgery

How to Build a Penis

Types of Bottom Surgery

Erection, standing to be & sensation

Pros/cons for meta/phalloplasty

Previous Masterposts:

Transmasc Presentation

Transfem Presentation

HRT Masterpost

Top Surgery Masterpost

Breast Augmentation Masterpost

Coming Out Masterpost

Gender Questioning Masterpost

Masterpost for Trans Allies

Choosing a New Name for Yourself Masterpost

Self Care Masterpost

Writing Trans Characters Masterpost

Transgender Pregnancy & Fertility Masterpost

Chest Binding Masterpost

[saltypringl-track]

Okay, trans guy here, I have not had any form of bottom surgery yet but I've done a lot of researching recently so heres what I got:

Theres two forms of dick-giving surgery, metoidioplasty and phalloplasty

Metoidioplasty requires you to have been on testosterone for at least a few years in order to get a significant amount of bottom growth. The surgery then removes the hood of the clitoris so it can stand erect away from the body. This results in a small dick, from about 1.5-3 inches depending on the amount of bottom growth you had. Metoidioplasty dicks can get hard naturally, the same way they would before surgery.

Phalloplasty is more constructive. A skin graft is taken from either your thigh or arm and it is used to create a penis and balls. The nerves from your clit are redirected to the new surface of the dick. Phalloplasty dicks cannot get hard naturally, instead they are inflated with a pump inside the ballsack. Phallo dick size is affected by your weight and size, ie the more skin in the donor site (your arm/leg) the girthier you can be, and in discussions with your surgeon you will be able to find out your range. Unfortunately I cant find any hard and fast "phallo dicks range from x to y inches long" stats but I do know that a well-done phalloplasty dick is pretty indistinguishable from the average cis man's dick.

(Fun fact the use of skin grafts for phalloplasty means that if you have a tattoo on the site used that tattoo ends up on your dick, and I think thats incredible and more trans guys should take advantage of it)

The tl:dr is that post-op dick size largely depends on your body's pre-existing assets and the type of surgery youre comfortable with. Talking to a surgeon will give you much more personalised advice as to the type of surgery and size thats best for you. Ultimately theres no Optimum Dick Size thats better than any other, its all personal preference and vibes, so follow your heart <3

...or dick

Question for penis master chan.

What size of penis do u recommend for like bottom surgery bc I'm trans and want a penis but I'm too fucking scared to ask my close male friends so I had to resort to my final shot, penis master chan.

Hope you have a penisily happy day or wtv

Oh honey this is not something I can answer for you! This is a you question. It’s a very personal decision. And I don’t know much about this subject, but I would venture to guess that you may not have as many options for the size? This may depend on your options for surgery where you live.

Perhaps you could try experimenting with different size packers till you find when it feels right?

Anyone have advice or suggestion for anon?

[phalloplastytime]

Phalloplasty Consultation with Dr. Chen & Dr. Watt

Here is what I remember from my experience going through my consultation with Dr. Chen from GU Recon (his private practice) and Dr. Watt from the Buncke clinic in San Francisco, CA, USA. My apologies for the length, I wanted this to feel kind of immersive for those of us still in the waiting process because stuff like this helped me. Also - small content warning I do use a couple anatomical terms.

For those of you unfamiliar, Dr. Chen is a urologist and Dr. Watt is a microsurgeon.

My partner and I traveled down to San Francisco to stay for two nights. We flew in on Thursday evening and flew out on Saturday evening, not wanting to be gone for too long and rack up even more expense on the hotel bill. If I had planned ahead several months ago, I would have tried to stay at the Quest House during this time but I didn’t realize a short stay was potentially possible. 

We are fortunate to be able to use the public transit system offered in SF, which is pretty good in my opinion. They have buses, trolleys (cable cars?), and an underground/train system. We utilized this to make our way over to Castro street, where the medical office building and also the hospital are located. 

Without any plans for the day we went ahead and headed over about 3 hours early because I had seen that there was a dog park right nearby. We sat and watched local dogs come and play and have a break in the middle of the day and we ended up meeting an older gentleman whose dog wouldn’t leave us alone asking for pets. It was pretty great, and nicely calming as I was pretty nervous before the consultation. We then got some food at the local cafe on the corner. It was actually pretty good. 

We realized we still had time to kill so we decided to hike up the hill to the Buena Vista park where we looked out over the city and rested for a bit. There’s a path that has some disturbingly friendly squirrels on it.

About 30 minutes before my appointment headed over. Inside the medical office building, Dr. Chen’s suite is right across the hall from the Buncke clinic. I wasn’t sure where to go to check in, so we walked all the way down to the entrance of GU Recon and saw the door was open. Inside the waiting room was fairly spacious with comfy seating and plenty of random coffee table books to peruse. There was nobody else there at the time. At the receptionist window was a sign indicating to check in over at the Buncke clinic, so we quickly hopped across the hall. 

The Buncke clinic waiting room was much smaller and was actually quite crowded for a Friday afternoon. I checked in and they asked for my ID and insurance card (even though I had sent in pictures), and they didn’t ask for any kind of copay or payment. I suspect I will receive a bill at some point for the specialist copay from my insurance which is $30. Hopefully.

They instructed us to head back over to Dr. Chen’s office to wait, so we went back over and started looking through a photography book. At this point I was still about 25 minutes early to the appointment so I was ready to wait however long it would take. 

About 5 minutes later, Dr. Chen himself appeared behind the reception area with pizza and Starbucks in hand, apparently not expecting anyone to be in the waiting room. He noticed us right away and began apologizing for the wait. He explained the schedule didn’t indicate whether or not we were having a phone consultation, so he just assumed it was going to be over the phone based on my address. 

This whole interaction solidified every good thing I had heard about Dr. Chen, and I immediately felt so… normal. That’s the best way I can describe what I felt. I felt like I had known Dr. Chen for years and that he was.. reachable. Human. 

He told us it would be a few minutes, and sure enough a few minutes later Dr. Chen and Dr. Watt appeared at the door and we made introductions. My partner came with me because I wanted her to hear what the doctors had to say and I wanted another pair of ears listening, and also because I wanted the doctors to see that I had support. 

We went down a narrow hallway and went into Dr. Chen’s office, which hosted another comfy couch which he had us sit on while he and Dr. Watt sat across on office chairs. They each had some papers (my medical information). The room was somewhat dimly lit, but calming and comfortable. 

The consult started with Dr. Chen confirming my reason for the visit (seeking phalloplasty), and he asked me how important it was to me to stand to pee. I explained that my personal goals were 1 - Sensation, 2 - Stand to pee, 3 - Aesthetics, and 4 - Sexual function. Which, again, are personal goals and it is completely valid to have other priorities with lower surgery. This is my own journey. 

We then went over my medical history, which is fairly short, but Dr. Chen was thorough and asked me about my minor eczema, asthma, and migraines. Dr. Watt was quietly taking notes and listening during this time. Next, they asked about any trauma to either arm and I basically explained how my right arm is essentially immediately disqualified from being a donor arm. In my specific case, I broke my right arm when I was 18 months old and had to have a surgical repair. This repair didn’t heal correctly and now my arm when extended is quite crooked. 

This has put some strain on my ulnar nerve and gives me hypersensitivity in my palm.  Further, I had a different surgery on my forearm which involved an incision and left me with a scar right in the middle of the graft area. This could compromise the blood supply, so we pretty much immediately dismissed my right arm as an option. To top it off, it is my dominant arm for most activities. I kind of would have preferred to keep my left arm nice and clear of any scars, but I think having 1.75 properly functioning arms is preferable to only 1 functioning arm in case my right side nerves ever gave out. 

Next, Dr. Chen went on to explain his portion of the surgery - he starts with the vaginectomy and then relocates the end of the urethra to the natal phallus using labia minora tissue. He then mobilizes this and relocates it to the other side of the pubic bone to come out to the site of where the neophallus will be placed. At some point during this discussion, Dr. Chen explained the complication rate and he was both realistic and optimistic about it. He said the vast majority of complications that happen are fixable. Further, the most common complications often heal on their own. I can’t remember the exact numbers, but he said of the patients that do have fistulas, only around 20% of them end up needing a surgical fix. Strictures don’t show up right away, and usually occur within the first year. 

While Dr. Chen does the work down below, Dr. Watt explained his team mobilizes the RFF and prepares it for the new location, using the tube-in-tube method to create the urethra and phallus. Dr. Chen places a foley catheter through the neophallus and into the relocated urethra to line everything up, and he sutures everything together once the microsurgeons connect the blood supply and nerves. Dr. Chen then places the suprapubic catheter and the RFF site is covered with the split-thickness graft from the leg.  If requested, Dr. Watt would place integra on the RFF donor site before the split thickness graft (not staged like other teams).

They then explained what recovery typically looks like - 5 nights in the hospital, including 4 days of strict bed rest and then up and walking on day 5.  If you’re able to walk well enough, you get to leave to recover elsewhere. They then check up every week for four weeks before sending you home. During your 1 week post-op visit, Dr. Chen removes the foley catheter from the neourethra complex. You start your peeing trials just before the 3 week checkup, and if you’re able to empty enough of your bladder the SP catheter can be removed. If you have significant fistula(s), an additional week for healing may be allotted and the SP catheter retained for that time. 

Dr. Watt then did an exam of my arm, performing the Allen’s test to see if my hand receives enough blood if the artery they harvest for the RFF is removed. The test seemed really quick, but I guess with how fast my hand refilled with blood he was very confident I was a candidate for RFF. He indicated that no further testing of my forearm blood supply was needed. 

He examined the hair on my forearm, which turned out to be really funny because while he was looking at it he guessed that I had undergone electrolysis up to about 6 inches down my forearm. I laughed a little and explained nope, I just haven’t grown hair there in my ~5 years on testosterone. He gently pinched/grabbed the skin to see the thickness and said they’ll likely delay my glansplasty, and when he looked at the underside of my arm where the urethra graft would be taken he said I was basically hairless there and that any electrolysis at this point would just to be to remove hair from what will be the outside of my phallus, which is optional and he said I can always shave or use something like Nair. 

I then had a chance to quickly look over my questions to try to find any that hadn’t been answered. They were pretty thorough so the most I asked about was about Integra because I was most curious about it. Dr. Chen then explained that he needed to do a quick visual exam of the genital/mons region and we walked across the hall to an exam room.

He apologized for the discomfort and had me just quickly drop my shorts while standing. All in all I think it took about 5 seconds of exposure. When we got back into the other room he reported to Dr. Watt something along the lines of “minor prominence” of the mons. I checked my questions one more time and asked if they had any testicular implants that I could feel, but Dr. Chen explained that he had a patient waiting that was somewhat urgent and he promised that he would show me next time. He was very polite about it and I understood, and all in all I think the consultation took about 30 minutes. 

We said our nice to meet yous and goodbyes and Dr. Chen showed us out the shortcut out of the clinic and boom it was over. Despite the quick ending, I still didn’t feel rushed out of there and felt like they really took the time to make sure I understood the surgery and that my possible concerns were heard. 

All in all I left feeling really good, which for me was everything. I was actually excited about the future. Also, they said they would be forwarding my information to the phalloplasty team about our consultation, and that they should be reaching out to schedule with me. What ended up happening was I emailed Logan with a follow-up question and after we emailed back a forth a couple times, Logan asked me if I wanted to set my date. So now I am officially on the books for Left RFF Phalloplasty and words cannot describe how much joy/relief/excitement I feel about it. 

Like, I still can’t believe I get to do this and I don’t know when reality will set in. But for the first time in months, I am hopeful and optimistic about the future. 

Edit: I forgot to mention that Dr. Chen also will perform a scrotoplasty during his part of the procedure.

[supercodi]

I am two years post-op phalloplasty today. Hard to believe two years have already gone by! 😮 . . Going into surgery I had no idea that The next couple years would be filled with having surgery every few months or so... either for a stricture repair or an arm graft revision. However, I am happy to report that I am now stricture free and I only have one more phalloplasty surgery ahead of me and that is for the erectile device in September. This chapter in my life is finally coming to a close in the near future. People always ask if it was worth it with all of the complications it entailed. 100% yes! No ones life is complication free and to me, the biggest complication was not being born with a penis so really... how much worse could it get? 😂 This surgery was no easy task but I’ve come our way stronger in the end because of it. . . So thankful to be living in a time where medicine allows for me to feel more aligned in my body and for my surgeons ( Dr. Chen and Dr. Lin specifically). If you are thinking of pursuing phalloplasty in the future my biggest tips would be: 1. Research your surgeons and the procedure ahead of time. 2. Therapy: you will need to mentally prepare yourself for both good and bad outcomes and also post-op depression. ( its inevitable so don’t think you are special and will escape it ). 3. A good support system: Friends, family, etc. you are going to need help. Maybe even someone willing to wipe your butt 😆 . . Happy 2nd Birthday to my penis! ( usually people my age have actual two year olds and I’m just celebrating my dick 🤷🏻‍♂️) . . #phalloplasty #bunckeclinic #drchen #drlin #pridemonth #pride #trans #transgender #transman #ftm #bottomsurgery #lifewillbethedeathofme #phallo #happybirthday #transguy #tbt https://www.instagram.com/p/Byqzf1fAqsz/?igshid=338qg3gdu6cv

[zero-ohms]

Life Update

I haven’t talked a lot about my life surrounding phalloplasty on here, partly because I’ve spent a lot of time recovering from surgeries, and partly because this surgery has marked a huge change in my life, and where I want to go in the future. It sounds corny, but my perspective on life has changed drastically throughout this surgical journey.

In summary:

1. I resigned from my job in California 2. I moved back to Toronto 3. I decided to pursue medicine

Having been exposed to medicine so much throughout my transition has created an interest that I never expected. I connected with many post-op people along my journey, and saw the frustrations with difficulties accessing care. Many of these obstacles put our lives on hold, manifested in physical pains, and resulted in mental exhaustion. There’s a huge gap in healthcare for trans folks that has been unmet for a long time. I realized I could make some serious impact in this area, in ways that I never could as an engineer. Not to mention, it’s an interesting field. I have a couple of pre-requisite courses to make up, as well as the MCAT ahead, but I’m aiming to apply to med school at the end of this year. No idea if this will work out, but it’s worth a try.

In the meantime, back to being a broke student and juggling surgeries.

[wildberrybunny]

First off - It's been a while! Hi! I'm over the 2 year mark from my phallo surgery, and in addition I went for stage 2 (urinary hookup) this past May.. putting me additionally at 5 months post-op! "patience is a virtue." Yes! Feeling has returned to my genital area/spread up the shaft as intended. I'd say the 1 year mark was when I really started to get the full feeling. My rating at over 2 years (June 2021): The shaft is not as sensitive as my pre-surgery genitals, feeling has spread to approx 90% of the shaft. Overall I'm satisfied because this was ultimately the goal. I went into it not expecting perfection, but a result that was satisfactory. I ended up waiting longer than I thought to finally get stage 2, but it's such a relief being able to pee from my penis now (previous to the hookup I still had to sit) Lastly my arm. I'm planning tattoo cover-up over the scar tissue. I've been largely successful in regaining strength in my arm. It is stiffer than my right arm, and the graft section doesn't have much surface feeling (if that makes sense) where the nerves were taken.. but I've seen that as a necessary sacrifice. Thoughts on stage 3 phalloplasty (The last stage): Testicular implants and a rod which allows for intercourse. I'm unsure if/when I wish to go forward with stage 3. These past 3 years I did stage 1, 2, plus (like a goof) broke my ankle really bad between those. Since I've been really happy with how my body functions, I won't be doing more surgery at least for some time. Additionally, at least right now intercourse isn't that high on my priorities.

Updates have become more sparse as I've reached the end points of my transition... But to anyone who has continued to follow my journey, I hope you've enjoyed it! It's crazy to look back almost 10 years now when I first came out, started T, looking into surgeries... where I began this blog "My Eventual Penis." :)

It’s finally happening; in two days I’m undergoing stage 1 phalloplasty!

[tontherocks]

Phallo Consult

On January 24 I had my consult for phalloplasty, done in three stages (phalloplasty, then UL, scrotoplasty and glansplasty, finally implants and ED). I had my appointment in the early afternoon with one of the four surgeons of this team. He was in his late 30s, friendly, appeared a bit hung over and tired. Our conversation was more equal and on a shared level than with the surgeon for my meta one year ago.

Since I already had an initial consult in this clinic in October 2017, I was familiar with the basics of this surgery and we only talked about the questions I had prepared. I give here an overview about the information I got - I don’t intend to quote the surgeon by any means, everything is absed on my best ability to understand the procedures.

Penis

During first stage, they take a graft from my left arm. The donor graft has a length of 15cm and a width of 15cm on the upper part of my forearm, 11cm on the lower part, near my wirst. Usually, the expected penis size is around 12.5-13cm in the long term, since it’s expected to lose around one cm in the weeks after surgery.

There are no data avaiblable about how much re-gain tactile / warm and cold / erotic sensation throughout their penis, hence nobody really knows when and how much sensibility to expect. There is no known possibility to help or enhance the development of sensibility in my phallo penis.

Their team dos 2-3 phalloplasties each week for at least 15 years, so aorund 100-150 annually. He himself has like 8 years of training with phallo procedures.

He showed me the microsurgeons he works with, all three have at least two decades experience with phalloplasty.

Complications

He estimated the probability to develop one ore more Fistulas by some 10%ish, Stenosis 5% and Diverticula some more. One of the main reasons for the latter are the different diameters between the urethra, created by my former labia minora, now residing in my meta penis, and the urethra, created by tube-in-tube-method, in my phallo penis. During my surgery they can estimate how narrow/wide my meta urethra is and thus, how much “leap” between the two forms of urethras. They will cut into the tip of my former meta to fuse both urethras.

All in all, he assured me that there were only 5% of complications that need to be adressed in a seperate surgery, every other minor complication can be fixed during one of the next stages.

Donor site

The clinic highly recommends RFF and rarely performs ALT (abdominal isn’t offered at all). We talked about my thight as possible donor site, but he strongly discouraged me from this option. His arguments were that 1) the skin is thicker than on the arm, hence less sensible 2) pain during movements is very common with ALT and sometimes results in chronic pain and that 3) this type of surgery is more prone to complications since they have to cut through muscle to harvest some of the nerves. The surgeon also favours RFF because of better sesibility. I was already familiar with their dislike for ALT and so I kind of never considered it as a possible donor site for me. ALT is rarely performed, hence less experience with complications as well, and since security is important to me, ALT really doesn’t seem to be suitable right now.

The surgeon never heared of Integra before and they don’t work with tissue expanders either. We watched a video from their Website and the surgeon said that they prefer a full-thickness graft over a split-thickness graft (as they usually do with Integra). The transplantat has to be rather thin since it has to be nourished by tiny blood vessels, so the leap between the donor site and the area around it is inevitable.

They take a full thickness graft from my lower belly to cover my donor site. The graft has a trapezoid shape, 40cm long, 5cm width and they sew it together, eventually, so there only remains a thin scar line from hip to hip, right where my underwear is supposed to end. The length of the scar depends on how much the patients weighs, since bigger patients need less space to harvest a graft. The surgeon told me I had to expect to have a full-length scar in this area.

Lympthatic drainage for the donor site is provided initially after surgery.

Stages

The second stage (glans- and scrotoplasty, UL) can be scheduled at least 3 months after first stage, they recommend 6 months. It reduces the probability for complications related to the new urethra.

It is possible to adjust glansplasty to the indvidual wants and needs of a patient, since its merely an aesthetic concern. We will talk about it after first stage. During the hospital stay of each stage there is an appointment scheduled to talk about the next stage.

Medical tattooing can be done around 1-2 years post-OP.

[truthfulrebellion-blog]

Hysterectomy

Let’s call it what it is. No pussy footing around it. A necessary evil on the way to the end game: phalloplasty. I had been waiting almost six months to hear back about my approval for phalloplasty. I currently have health insurance through Kaiser Permanente, and they had a laundry list of things for me to do in order to present my file to the medical board. I had to transfer my files over from the organization I was seeking healthcare through, as it was cheaper than paying out of pocket for an endocrinologist, to Kaiser. I also had to obtain letters from two medical professionals confirming my need for bottom surgery. The whole process took nearly a year and several trips to medical facilities nearly thirty miles away from my home. My case manager finally called and said in order for the final review to occur, I had to get a hysterectomy.

At the time, I thought that was done by the surgeon performing the phalloplasty at the time of the phalloplasty. With Kaiser, that is not the case. They want anything and everything they have the capability of doing done within their facility. Likely to keep costs down. I didn’t mind. My hysterectomy was scheduled for December 15th, 2018. I had to get blood tests done and watch several videos that didn’t pertain to my situation regarding the procedure. The videos are, obviously, geared towards women. I did what I needed to do and prepared myself for the surgery date. I got a call to move my surgery up about 10 days, even better. Then not 24 hours before the surgery, I received a call stating that it was being delayed for a week. My new date was the 11th. This was terribly inconvenient as my care giver for after my surgery had already taken off work for the original surgery date.

I walked into the facility to check in about an hour early. I had yet another interesting surprise. The surgery was going to cost me money. $475, or close to it. Luckily, I had the money. I was very upset that I wasn’t told about this ahead of time, however. I am paying for the most expensive coverage this company offers so I had as little to pay out of pocket as possible. In the grand scheme of things, $475 is better than $10k. It still would have been nice to know before I showed up. If you have Kaiser, please make sure you know exactly what the costs are before you walk in the door.

I got checked in. I had to remove all of my clothing, put on a hospital gown & surgery cap, and take one final per break. I also forgot to mention I had to stop eating at midnight the day of and wipe my body down with these pre-surgery wipes. I was hungry and my skin smelled weird. They hooked up my IV, fed me my “lunch”, and several doctors came in to ask me questions and verify information. My surgery was supposed to occur at 3pm, but was delayed until closer to 5/530. My surgeon came in to make sure I knew what was about to take place. He also talked to me about a surgeon for bottom surgery in Arizona or New Mexico he was going to refer me to. He had given me the name in our prior consultation. When I looked that surgeon up, I was horrified. The man was fired from the California region Kaiser Permanente for botching transwomens vaginoplasties. The guy didn’t even specialize in phalloplasty. I expressed these concerns to him and told him it probably wouldn’t be a good idea to partner with him for any trans surgeries. Hopefully he heeds my advice. He confirmed that after the surgery, he would stick to the decision to refer me to Dr. Jens Berli of Portland, OR.

I knew nothing of Dr. Berli. There are no results to been seen online, barely anyone who has undergone his procedure even talks about their results, and I couldn’t find any other information besides his starting point in Maryland. I found his Facebook page and did some pretty intense research on him. He seems to genuinely care about his patients and has a passion for what he does. His only negative review is from someone who never had surgery with him because of a communication issue with his staff. Everyone else gave him five stars. So, I figured why the hell not. Hopefully my progress will help others who may be going to Dr. Berli for their phalloplasty be more comfortable with moving forward with him or the surgery itself. I am flying as blind in this moment as some of those who might read this in the future might feel. Trust me. I feel your pain.

I finally went in for my surgery. This time I wasn’t put under until I was on the surgery table. For my top surgery, I was out before I turned the corner on the way to the operating room. The next thing I remember is waking up several hours later and in pain. I couldn’t keep my eyes open. I was very disoriented. I’m not surprised considering I was on anesthesia. Apparently I wasn’t breathing enough either since my O2 alarm kept going off. I had to stay for an extra hour until I could get my breathing going regularly. Which is hard because I believe I have sleep apnea, and when I sleep I breathe much slower than I do when I’m awake. So I would fall back asleep, stop breathing, and be woken up by the nurses to get me to breathe. I didn’t feel any different than I usually do. I was actually quite comfy. But I’m sure it was uncomfortable for others around me to see me breathe 1-2 times a minute while asleep.

I was in so much pain. The pain meds hadn’t kicked in yet. I had had a total hysterectomy, oophorectomy, and partial vaginectomy. Let me tell you. When your genitals are covered in stitches, sitting fucking hurts. I couldn’t get comfortable. Then I had to go to the bathroom. Lord, that was an adventure in of itself. Once I was done, I had to have the nurse help me pull my maternity disposable underwear and extra absorbent pad on. And to help me get dressed. The was a humbling experience. But those disposable underwear are comfortable AF. I wish I had had more of them. I was only sent home with the 1 extra pair. After I got dressed, they sent my care giver to get the car. They sat me in a wheel chair and wheeled me to the pick up area. Wheel chairs are super uncomfortable. I begged the nurse to let me sit on the plushy waiting area seat, but she told me no. I couldn’t wait to get out of that chair. It hurt so bad.

I’ll spare additional details about the trip home. I was basically in pain in the seat, it took over an hour to get home, and I got right in the couch seat I’d be in for the next week and fell asleep. I had to wake up every 1-2 hours to pee and every 4 hours to take my pain meds. Compared to my chest surgery, the pain of the hysterectomy actually wasn’t too bad. I barely needed any medicine. The worst pain came when I peed. It burned like the surface of the sun, and I could barely get the urine out. This lasted for about 2-3 days. I was bleeding pretty regularly for 1-2 weeks and spotting until the 6th week. I had horrible colored discharge the entire recovery. I actually had to go get adult diapers when my last pair of those comfy underwear got worn out. I couldn’t find any of those huge puffy pads or anything without adhesive.

I think the worst part was not being able to poop. I could feel the poop in my back. I really could. But I could not get my bowels to work. Apparently, this is normal. I ended up pooping on day 5. Best advice? Take stool softeners religiously. I would go so far as to say take a laxative on day 3 or 4 because that poop is going to be quite solid. TMI alert, my first poop after surgery tore a little bit of the inside. Like a hemorrhoid. I’m getting into these details because I wish I had had them. It’s not rainbows and butterflies. It’s bleeding and inability to poop. I also could barely sleep as I had to sleep on my back, and I can’t sleep on my back. I get so unfortable. By day 3 I was sleeping on my side on the other couch. I’m also a bigger guy, so I had to hold my stomach when I got up since there was a lot of pain from my belly hanging. I’m not 300+ pounds or anything, but I do have a beer belly. If you are the same, just be prepared for tummy pain when getting up.

I slept on the couch for 3 weeks. It was so much more comfortable than my bed. And it was easy access to everything. I am almost 8 weeks post op and still get tummy pain. But for the most part, pain and blood free. I do still have discharge coming out. I’ll probably continue to wear the diapers until I run out just in case. I had already ruined a pair of pants when I thought the discharge was done. But after about 7-10 days, I was walking around and driving and doing what I needed to do. It was uncomfortable to sit and bend over, so my roommate had to help with a lot of things. My final observation is to leave the scabs alone. I accidentally picked at my belly scab and one of the dissolvable stitches came loose from my incision. I had that stitch hanging out for at least 2 weeks until it finally dissolved at the base and popped off. My scars look great and my hair has finally grown back on my stomach.

I’m doing all of this well after my surgery, so I am sure I have missed a thing or two. If you have any questions, please give me a comment or a message. I will answer anything.

[juniperpublisherscasestudies]

Juniper Publishers- Open Access Journal of Case Studies

Lipografting - and Sculpturing in Female-to-Male Transgender Patients

Authored by Delia L Francia

Abstract

This case report presents several surgical procedures that amply lipotransfer and -sculpturing to treat specific volume sequelae and scar-related impairments in FtM patients after failure of conservative surgical primary therapy. From November 2016 till November 2018 three FtM patients with typical scar related sequelae underwent sequential lipografting – and sculpturing. Our minimally invasive operative protocol (ACRT) was combined if required to a gender reassigning liposculpturing of the trunk or forearm augmentation for flap preformation. Clinical and aesthetic outcome were measured with photographs, the Patient and Observer Scar Assessment Scale (POSAS), Visual Analogue Scale (VAS) for pain, ROM measurements and nerve conduction studies (NCS). In all three patients a relevant functional and aesthetic improvement was achieved associated with very short hospitalization (average 3.2 days) and minor complications like swelling or bruising of the donor site. Clinical outcome showed improved scar appearance; 55% mean decrease of pain perception leading to 37% higher ROM in the left wrist mostly in extension. Increase of neophallus’ size or forearm’s subcutaneous layer prior to phalloplasty as well as a typical V-shape masculine trunk were accomplished after maximum three procedures.

Keywords: Liposculpturing; Fat grafting; Transgender surgery; Scar therapy

Abbrevations: FtM: Female to Male; ACRT: Adipose Cells Derived Regenerative Therapy; POSAS: Patient and Observer Scale; VAS: Visual Analogue Scale for pain; ROM; Range of Joint’s Motion in Degrees; NCS: Nerve Conductive Studies /Measurement for Electrophysiological Functionality

Introduction

Lipografting is emerging as a treatment for postoperative sequelae, namely postoperative or posttraumatic contour and volume defects as well as dermal scars [1,2]. Liposuction may serve to remove excess volume, whereas lipografting of the harvested adipose tissue can be used to enhance and restore soft tissue volume defect [3-6]. Furthermore, lipografts remodel scar tissue by unknown mechanisms, which improves the elasticity and aesthetic aspect of the skin [7]. Another important feature of lipografting is pain reduction in neuropathic scars [8,9].

A group that could benefit from lipografting as a reconstructive treatment option for postoperative sequelae are patients suffering from gender identity disorder, that opt to undergo or underwent female-to-male (FtM) sex reassignment surgery. The term gender identity disorder is used for individuals, who experience a strong and persistent cross-gender identification and a persistent discomfort with their anatomical sex, as manifested by a preoccupation with getting rid of one’s sex characteristics or the belief of being born with the wrong sex [10]. It is a relatively rare condition, with a prevalence roughly estimated from 1:30,040 to 1:104,000 in assigned females [11]. However, the prevalence of operative male-to-female transition is four times higher compared to female-to-male. Traditionally, the process of FtM transition is a staged. Initially, hormone therapy with testosterone is started to induce virilisation [12]. Then, the first stage of surgical sex reassignment is usually a subcutaneous mastectomy, which may be combined with hysterectomy and bilateral salpingo-oophorectomy. The second stage involves phalloplasty or metoidioplasty, combined with scrotoplasty and eventually with vaginectomy [13,14]. Although several techniques for phalloplasty e.g. anterior thigh flap, suprabubic flap, lattissimus dorsi flap are described the literature, the radial forearm flap phalloplasty is the most frequently performed [15]. After successful microsurgical transplantation a penile prosthesis, i.e. an inflatable erection device, and testicular prosthesis can be implanted [16].

The main functional and aesthetic aims of FtM sex reassignment surgery are micturition in standing position, visible bulk in under- or swimwear and preservation of genital sensation combined with the ability to achieve erection and penetration. These goals should be implemented in the therapeutic concept by surgeons, providing transmen an optimal fit in the desired gender role. However, sex reassignment surgery is linked to a high complication rate, while FtM patients also require numerous operative revisions to improve functional and aesthetic outcome [17]. Currently, no specific reconstructive treatment has evolved or particularly declared to improve the radial flap donor-site disfigurement, as well as functional impairment, i.e. in range of motion (ROM), due to the lacking subcutaneous adipose layer [18,19]. Furthermore, difficult-to-treat problems in FtM patients are painful and disfiguring scars on several body parts e.g. the pectoral or inguinal region. Genital skin irritation or pressure sores occur due to insufficient prosthesis coverage (i.e. penile or testicular implants) and frequent soft tissue volume defects (e.g. disproportionate scrotal or penile size) [20,21]. A remaining female aspect of the whole trunk including a wide hip region even after standardized mastectomy and hormone therapy may cause persistent discomfort and has not been described in a selective plastic surgical procedure yet [22]. Hence literature lacks standard operating protocols concerning sequelae after radial forearm flap phalloplasty or unsatisfactory results due to penile reconstruction [23-25].

This report describes results of specific designed operative concepts in order to approach the aforementioned problems as indications to revision systematically e.g. by using our minimal invasive scar release concept called Adipose Cells derived Regenerative Therapy (ACRT) in typical scar regions [26]. The pectoral contours were enhanced by lipografting and combined to liposculpturing of the lateral flanks and abdominal part for utter masculinization of the trunk. FtM patients in different stages of their gender affirmation process were included and treated because of refractory symptoms or impairments after mastectomy, free radial forearm flap phalloplasty after total failure of conservative therapy. Clinical outcomes were measured after at least three months follow-up period in order to assess efficacy with a low complication rate.

Material and Methods

Refractory painful scar adhesions, disfiguring trunk/hip parts, poor penile size or prosthesis coverage were treated in 3 female-to-male transgender patients from 2016 to 2018. Each patient underwent 3 operative procedures (P1-3) and these cases were retrospectively reviewed (Table 1). Previously to operation patients received at least one year of conservative scar therapy i.e. massages, silicone gel, compression, intensive occupational or pharmacologic therapy. But despite these interventions all major symptoms persisted, i.e. scar contraction leading to an obstructive sensation of the forearm with decreased mobility of the wrist, allodynia, conspicuity of the trunk and neophallus aggravating stigmatization or persistent genital skin problems due to insufficient tissue coverage of the penile prosthesis. Ultimately, we addressed the phenomenon of decreased penile size due soft tissue shrinking after phalloplasty in two patients – on the one hand with engraftment of the neophallus and on the other with preformation of the forearm through lipografting before radial free flap transplantation. These indications had been listed for our investigation and to minimize treatment related bias, all operations were done by the same senior surgeon to minimize bias of surgery in post-op evaluations. The research was conducted in agreement with the ethical rules for human experimentation as stated in the Declaration of Helsinki. Demographical and clinical data regarding scar characteristics, perception of pain, range of motion were kept prospectively as a part of a research on lipografting on scars, approved by the internal Medical Ethical Committee (METC 167/2015MPG43). All patients gave written informed consent after being informed about the procedure and its consequences.

OR-Time = Operation -Time, min = minutes ; P = Procedure.

Surgical Techniques

Patients presenting with either radial flap donor site scars or pectoral scars after mastectomy, were treated according to our standardized minimal invasive scar release procedure called the ACRT protocol [26]. In brief, the scar tissue of at the radial flap donor site or on other body parts was loosened by means of a minimal invasive scar release technique through maximum two stab incisions. Intra- and subdermal fibrotic tissue was undermined strictly horizontally to the skin level with specific sharp needles of different diameters (16 to 22 Gauge). Each scar area (15 to 80cm2) had to be individually prepared for the grafting of lipoaspirates by following the projected spider web like design. The lipograft was harvested from the abdominal and hip region using the body-jet system with modified Klein’s tumescence solution for waterjet assisted liposuction (human med AG, Schwerin) [27]. The liquid consists of isotonic saline solution supplemented with epinephrine (final dilution 0,0001%, Infectopharm), Xylocaïn (0.049%, Astrazeneca GmbH) and sodium bicarbonate (1.48%, Fresenius Kabi Deutschland GmbH). While waterjet assisted harvesting, the lipograft was contemporarily washed and filtered through the Lipocollector III°- System (human med AG, Schwerin). Portions of 50cc were decanted and after 7min transferred to 10cc Luer-Lock syringes. Fat was re-injected intra - and subdermally into the pre-treated scar area with a 7 to 12cm long blunt tip cannula. Stab incisions were closed by temporary single sutures and dressing.

In order to gain a more masculine aspect of the chest wall and the abdominal part, we planned and marked the different areas of the trunk to address (Figure 1). By using a 3.8mm sized multiple-hole cannula and water jet assisted liposuction the determined refinement of the hip and lateral thoracic part was performed in the first place. Preparation of the lipograft occurred with the Lipocollector III°- System and the adipose tissue was prepare in 10cc Luer –Lock syringes ready for reinjection. One stab incision was placed on each side in the lower margin of the NAC. Subdermal and intramuscular lipotransfer took place with 7 to 12cm long blunt tip cannulas. In this way the inner and lower margins of the pectoral muscle were enhanced and underlined the masculine pectoral contours. Intraoperative the patients were sat in an upright position in order to control stepwise the symmetry and bilateral engraftment. The selective liposuction of excess fat on the abdomen, hips and flanks generally lead to the characteristic V-shape of a masculine trunk. Stab incisions were closed with single prolene sutures and covered with sterile dressings. The grafted area was cushioned with soft cotton bandings and a tight-fitting compression garment was put on in the operating room. Postoperatively, all patients received antibiotic treatment with cefuroxime 500mg per OS three times daily for a total of 5 days. A cushioned dressing was applied to the recipient site in order to avoid pressure on the lipograft for at least 10 days. In case of radial flap donor site augmentation, splinting was used for five days to avoid muscular tension or shear forces on the lipograft. Temporary sutures were removed after 5 to 7 days during routine control. Compression on the lipograft donor site was carried out for at least 4 weeks and muscular stress or sports were only allowed afterwards. Followup controls took place after one week, one and three months postoperatively.

Results

Almost all nine interventions contained at least two surgical techniques e.g. trunk liposhape combined with ACRT on several body parts with a median operation time of 120min (range 83 to 153min). On average 129cc of lipograft (range 80 to 246cc) was used per procedure with a total mean volume of 735cc per patient. For the trunk liposhape 160 to 200cc was needed and a total of 205cc was inserted for penile and scrotal correction. We recorded no major complications, but two minor complications in nine interventions due to our operative techniques. The first complication consisted of allodynia in the form of an electrical sensation and numbness in the first three fingers after lipografting in the radial flap donor site, indicating compression of the carpal tunnel. These symptoms were managed with conservative treatment and subsided spontaneously after five days. The second minor complication was haematoma formation after liposuction, which was treated conservatively and subsided after two weeks. Of note, none of the patients developed infection, donor-site irregularity, reactive scaring, oil cysts, fatty clumps or showed insufficient reuptake. Scars related issues and painful impairments were objectified by questionnaires (POSAS, VAS) preoperatively and 3 months after P1 and P2 (Figure 2). Benefit resulted by a notable reduction of the total scores for patients (50.5/25.0) and for observers (43.0/19.5) respectively. VAS also reduced, indicating a relief of pain due to the procedures applied. Preoperatively measured ROM and Tinel signs on the forearm improved mean 36.5% mostly in extension and radial abduction after the sequential subscar fat injection.

Case Reports

Case 1

33 years old non-smoker with a BMI 28.4kg/m2, was enrolled in November 2015 for a painful scar adherence on the donor site two years after free radial forearm flap transplantation. He presented a skin type V according to Fitzpatrick with hypertrophic scarring and high pigmentation also on the pectoral area. Full skin graft originated from the inguinal area presented severe scar contraction on the left forearm and led to lessened movements such as 40°extension, 10°radial and 25°ulnar abduction in the wrist. The patient complained about an obstructive sensation due to the reduced circumference on the proximal and distal edges of the scar area (Figure 3A). A Tinel sign was detected 1.7cm distal and 3 cm proximally the superficial radial nerve area. Hypersensitivity led to a reduced quality life, e.g. the disability of wearing long arm clothes. Prior conservative treatment with silicone gels and sheets, compression garments and massages failed to alleviate patient’s complaints. Besides overweight and conspicuous scar formation brought to an unpleasant aspect of the trunk and pectoral area (Figure 4A & 4A). We performed three sessions of minimal invasive scar release method to the forearm and with 80cc, 123 cc and 20cc of fat graft. After the first 3 months follow up the patient already gained 5° to 10° in the ROM of the wrist joint. Tinel sign was decreased detectable 1cm distal and 1.6cm proximally the radial nerve area, indicating a local cushioning or embedding effect of the inserted lipograft. After the next intervention functional impairments like neuropathic pain diminished even more. This was confirmed by reduced VAS scores from preoperatively 6 (nearly acceptable pain) to final 1 (almost none). Finally, the initial tethering scar aspect in texture regained high pliability and ROM in the donor wrist improved to painless completion (Figure 3B). By using the aforementioned trunk liposhape approach, we removed 390cc pure fat and transplanted 160cc graft volume in the predefined parts. In this way we obtained a dominant masculine aspect of the pectoral contours combined with a flattening definition of the lateral thoracic part, flanks, abdomen and hips (Figure 4C & 4D).

Case 2

33 years old non-smoker with a BMI 20.5kg/m2, showed in January 2016 painful and hypersensitive scar formation after free radial forearm phalloplasty with full split skin graft to the donor site in October 2012. ROM was reduced with 25°extension, 10°radial and 15°ulnar abduction. In addition, recurrent wounds and skin lesions occurred due to poor skin coverage of the penile pump system and right scrotal prosthesis. We noticed a peculiar shape of scrotal part and the neophallus after completed scar maturation and partial shrinking of the flap’s soft tissue (Figure 5A-5C). Before surgery the conservative treatment of the forearm consisted in massages, silicone gel, compression and steroid injection. Preoperative measurements detect a Tinel sign 4cm proximally and 2.5cm distal of the radial innervated field. Nerve conduction revealed a reduced velocity and amplitude of the left affected superficial branch in comparison to the opposite side (left 17.9mV; 59.9m/s vs right 86.3mV; 65.7m/s). Sonographic measurements of the skin layer determined a thickness of 0.9mm over the main branch.

Patient’s expectations on our operative therapy addressed alleviation of the obstructive sensation as well as neuropathic symptoms caused by the rigid circumferential scar area on the donor side, conspicuous aspect of the of the neophallus and left neoscrotum plus ventralisation of the right scrotal prosthesis. After the first operation the Tinel sign was reduced detectable 3.2cm distal and 1.4 proximally from the radial branch and ROM of the wrist improved especially 10° ulnar and radial abduction. The nerve conduction demonstrated a lowering of the amplitude after each fat grafting session, although the velocity persisted low (left 8.3mV; 59.9m/s vs right 85.7mV; 65.9m/s). Thickening of the local skin layer was estimated of 1.3mm by ultrasound. In the second session ACRT-concept on the forearm and penile area was done in combination to ventralisation of the right scrotal prosthesis and lipografting to the neophallus. Stepwise a soften coverage of the penile pump system in the left neoscrotum and widening of the penile circumferential scar have been achieved (Figure 5D-5F). In By loosening the fibrotic entrapment and thickening the subcutaneous layer on the donor side neuropathic symptoms decreased according to a Tinel sign 1.2cm proximally and 1.3cm distal. ROM rapidly improved and reached except 5° in supination painless completion. Questionnaires evaluation estimated a decrease of the Patients baseline POSAS score from preoperatively 88 to 48 as well as VAS scores from 8 (severe pain) to 2 (mild pain). However, he showed no recurrence of erythema, inflammation or wounds in the genital region during the complete follow up. Hence penile diameter increased 0.9cm and stayed stable in shape without problems in urologic or erectile function providing more self-confidence in patient’s sexuality.

Case 3

26 years old, smoker (10py) with a BMI of 28.2kg/m2 was planned for mastectomy as the first intervention after one year of hormone therapy. Since FtM patients’ complaints had been reported about postoperative soft tissue shrinking and decreased penile size after radial free flap phalloplasty, we conducted a pre-enhancement before flap harvest through sequential lipografting. The design of the future donor side was marked on the nondominant left medial forearm (Figure 6). We chose larger outlines, i.e. 20cm length in order to correspond an enhanced shape of the “prefabricated” flap after microsurgical transplantation. Preoperative clinical measurements recorded forearm’s circumferences, sonography assessed the thickness of the subcutaneous layer and controlled the vascularity during the prefabrication process on several levels: wrist (CIRC1), half middle forearm (CIRC2) and proximal forearm (CIRC3). In the first procedure the mastectomy and waterjet assisted lipografting of 116cc from the abdomen to the left arm took place. Afterwards hypertrophic scarring and an unpleasant aspect of the right NAC due to partial necrosis and wound healing problems were noticed (Figure 7A). In the second procedure we applied the scar release method to treat the right fibrotic deformed NAC and pectoral scar (23cc) simultaneously with the forearm augmentation through 94cc autologous fat graft harvested from both flanks. In this way we obtained symmetry in the pectoral part and a thickening of the subcutaneous layer of the left forearm. In order to provide a reliable soft tissue enhancement of the future donor side and a masculine aspect of the chest, the patient underwent a third forearm augmentation (96cc) combined to the trunk liposhape approach (Figure 7B). Here we removed 480cc fat from the abdomen, flanks and lateral thoracic area and transplanted 100cc subcutaneously and 70cc intramuscularly to enhance the pectoral muscle contour. Postoperatively forearm’s circumferences showed a mean increase of 2,6cm (ranged 0,8cm to 5,6cm) (Table 2). Furthermore, ultrasound measurements proved intact vascularity by Doppler and a successful engraftment in the “prefabricated” flap area (Figure 8A & 8B). In summary patient maintained excellent functional and aesthetic aspect of the forearm after insertion of 303cc lipograft with the technique described.

T0 = preoperative ; Tx = 3 months postoperative.

Discussion

The most important goal of female-to-male genital reassignment surgery is an inartificial masculine outer aspect accompanied with optimal penile reconstruction, which allows the FtM patients to void standing up and sexually interact with penetration [13,28]. Even though multiple operative steps are taken during the process, remarkable paucity exists concerning specific techniques to address persistent scar related disfigurements, donor side disability with neuropathic pain, trunk contour deformities after mastectomy, dislocation of scrotal implants or tissue expansion in the mean of secondary surgical corrections [29,30]. Our lipografting protocol combined with a minimal invasive scar release called ACRT was performed in the abovementioned three FtM transgender cases to improve the scar related complaints on the donor forearm after free radial forearm flap like rigid adherence, pain sensation in the superficial radial nerve area, decreased ROM, differing pigmentation, shrinking of the subcutaneous fatty layer. Upgraded appearance in scar area as well as a pliant skin texture measured by POSAS scale system, probably lead to complete painless ROM of the donor wrist. Obvious reduction of the neuropathic features registered through VAS Scores, Tinel sign’s exhibition, nerve conduction and ultrasound measurements, seemed to be linked to fat graft’s cushioning (mechanical) and regenerative effect recently described in scars in addition to minimal invasive release of fibrotic tension on the nerve [8,9,31]. Conversely literature reports, that scarring in the forearm’s skin graft do mainly result in functional and pain-free donor side with high patient satisfaction [10,17,18]. We feel, that the ACRTprotocol offers a powerful tool for systematic fibrotic loosening of the scar area without compromising the vascularity of the full skin graft in patients with persistent donor side’s complaints.

Furthermore, this technique was applied to treat aberrant scars due to conservative sex-reassignment mastectomy and radial flap based phalloplasty. In the pectoral area we corrected hypertrophic post-mastectomy scars and regained projection of the nipple. In the genital part we obtained a distension of the inguinal and circumferential penile scars, simultaneous lipografting lead to an enhanced and pendulous shape to the neophallus. Autologous fat transplantation with or without transcutaneous needling of fibrotic tissue has been generally described and proclaimed as promising treatment before [32-34]. Even though systematic transcutaneous needling accompanied by lipografting as synergistic methods in symptomatic scars have not been elucidated in detail or even established as a standard operating procedure(s) (SOP) yet [35,36]. Latter has been established as the ACRT-protocol in our institution for FtM patients with promising results so far. Although controlled randomized studies including a large number cohort are required to verify its evidence.

Scrotoplasty is usually performed with the insertion of silicone implants using the labia majora with or without prior tissue expansion or simultaneous advancement of local skin flaps [37]. Postoperative dislocation of the scrotal implants may provoke skin affections and a hidden aspect of the neoscrotum especially in the lateral view. Poor skin coverage with implant expulsion, mechanical dysfunction or dislocation are known as typical complications after insertion of a hydraulic balanced penile prosthesis [38,39]. To overcome these drawbacks even more surgical interventions and downtime periods are required. In case 2 ventralisation of the right neoscrotum and a cushioning soft tissue coverage over the penile pump system succeeded within short and easy to perform sessions. Follow-ups were uneventful and avert further conservative amendments. The use of lipografing to enhance the subcutaneous skin layer is widely performed in breast surgery e.g. to camouflage the outlines of breast implants [40-42]. However up to date there is no literature reporting the use of autologous fat transplantation for scrotal sequelae in FtM patients.

Ultimately lipografting offered directed soft tissue augmentation for the use of radial free flap prefabrication before phallic construction without notable complications in patient 3. Before different approaches were proposed to derate secondary corrections, functional and aesthetic impairments after phalloplasty e.g. specific closures of the donor side, prelamination with a tube for urethroplasty, or pre-extension by tissue expansion [43-45]. Most techniques include an additional surgical team during time- consuming interventions, notable major complications and prolonged immobilization or demand high patient’s compliance [46,47]. On the other hand, the presented concept of radial free flap prefabrication is surgically feasible as an ambulatory treatment and the forearm’s fatty layer might almost be doubled within three procedures in patients heading to forearm’s flap based phalloplasty. However, the operative approach is presented as a single case so far and must be investigated in a larger cohort including a longer follow up. Finally, pectoral lipografting combined to distinctive liposuction on different parts of the trunk was designed as Trunk Liposhape and led to improved upper masculinization. Our study has limitations such as a low patient number, short follow-up period, observer bias, but this pilot approach provided a first and preliminary impression about reconstructive techniques that have not been described for that patient group so far. Besides, all patients stated that they would undergo the same procedures considering the complications and postoperative results.

Conclusion

Lipografting - if a proper patient selection and operative procedures are applied - is a minimally invasive and patient friendly solution for aesthetic improvement of sequelae resulting from female-to-male sex reassignment surgery. Both symptoms and aesthetic issues create in this specific patient group a large burden in daily and professional life with a permanent reduction of the quality of life or psychological distress. Up to date therapeutic and surgical approaches are limited, that’s why the new concepts had been developed and applied as “rescue” procedures in our department with an acceptable safety profile.

The standard minimal invasive scar release protocol of ACRT combined with or without the Transgender-Trunk Liposhape (TTL) could be used in cases when all previous attempts of conservative treatment have failed. Further clinical studies with large numbered patient groups and recording of a long-term effectiveness are highly recommended and certainly necessary.

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[trucumber-blog]

A bit over 3.5 years post op (3 years post revision) top surgery with Dr. Fischer in Maryland. Hybrid procedure of peri-areolar with lateral extensions for excess skin from poor elasticity. - Almost six months away from RFF phalloplasty and 1 year in to hair removal for donor site (forearm of un-braceleted arm).