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Trans-Feminizing Bottom Surgery

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Trans-Feminizing Bottom Surgery Geoffrey D. Stiller, MD, FACS, FAACS Palouse Surgeons LLC, and Linea Cosmetic Surgery TRANS-FEMINIZING BOTTOM SURGERY 1 DISCLOSURES none 2 OBJECTIVES Determine the appropriate patient for this procedure Explain the work up required Discuss the option of surgery Understand the postoperative recovery Discuss the potential complications and the treatment 3 GENDER DYSPHORIA(DSM V, ICD10 F64.0) Involves a difference between one’s experienced expressed gender and assigned gender, and significant distress or problems functioning. It lasts at least 6 mo and is shown by at least 2 of the following: A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics A strong desire for the primary and/or secondary sex characteristics of the other gender A strong desire to be of the other gender A strong desire to be treated as the other gender A strong conviction that one has the typical feelings and reactions of the other gender 4 WPATH VERSION 7 CRITERIA FOR VAGINOPLASTY Persistent, well-documented gender dysphoria Capacity to make a fully informed decision and to consent for treatment Age of majority in a given country If significant medical or mental health concerns are present, they must be well controlled 12 continuous months of hormone therapy 12 continuous months of living in a gender role that is congruent with their gender identity 5 SPECIFIC HEALTH CONCERNS Cardiac workup Mental Health workup Urologic workup 6 LETTERS ? Required from provider managing hormonal therapy Outcomes of clients current hormonal therapy and when started Confirm the stability of current medical conditions Two mental health professionals Confirm the diagnosis of gender dysphoria using DSM V Assure the client is a good candidate Assure the surgery is the next reasonable step in care(medically necessary) Assure the client has no coexisting behavioral health conditions, which could hinder participation in treatment Assure any coexisting behavioral health condition is adequately managed 7 CONSULT We prefer seeing patients after we have received the letters The patient will meet first with our transgender consultant In depth discussion regarding goals Examination and discussion of surgical options The patient will again meet with our transgender consultant to explain the authorization process 8 OPTIONS FOR SURGERY No Vault or Zero Depth Vaginoplasty Penile Inversion Vaginoplasty Colo-vaginoplasty 9 NO VAULT OR ZERO DEPTH VAGINOPLASTY Creation of the normal female external anatomy without creation of vaginal canal Pt choice Medical conditions disqualifying pt from a vaginal canal Not able to perform dilation 10 PENILE INVERSION VAGINOPLASTY Using the penile skin tube to create vaginal lining May need scrotal flap or skin grafts for depth No self lubrication Dilations necessary Preoperative electrolysis may be necessary 11 COLO-VAGINOPLASTY Use the colon as the neovagina 12 COLO-VAGINOPLASTY Requires two surgeries Self lubrication Will need to wear pads May have an odor 13 PRE-OP The patient will meet with myself and my staff to again discuss the goals of the operation and potential risks Consents are signed Pre-op labs CBC, CMP, T&S, ? Nicotine Bowel prep the night before surgery 14 SURGERY DAY Will meet again to discuss goals of operation 3-4 hour surgery High lithotomy DVT prophylaxis Arm and legs padding 15 HOSPITAL 5 day hospital stay Bedrest the first 4 and ½ days DVT prophylaxis Antibiotics for 2 wks Planned constipation Hospitalist and Mental Health providers available if necessary 16 DAY 5 The big reveal Drains and foley catheter removed Packing and dressings removed Pt is taught how to dilate and clean Pt discharge after having a bowel movement and urinating 17 DISCHARGE INSTRUCTIONS Avoid strenuous activity for 6 wks. No biking or swimming for 3 mo No submersion in water or tub for 2 mo Swelling will last for a few month. Will worsen with activity Wash hands before and after contact with your genital area. Wipe from front to back to avoid contamination. Avoid tight clothing Vaginal discharge is expected the first 6 wks. May have some bleeding and spotting for 8 wks No smoking for 1 mo postop at least 18 DILATING INSTRUCTIONS Wash dilator with antibacterial soap Only use water based lubrication Gently insert dilators into the vagina at a 45 degree angle until under the pubic bone, then continue inserting inward at a 0 degree angle Insert into the full depth and leave in place for 20-30 min. Dilate three times a day for the first 3 months Dilate at least once a day during the 3-6 mo recovery Dilate at least every other day during the 6-9 mo recovery Dilate at least 1-2 times a week after 9 months If the vagina begins to feel tight, increase the frequency and duration of dilation Use soap and water to clean the vaginal canal after dilations 19 DILATORS 20 RECOVERY Pt needs to stay in the area for 2 wks at least Follow up visits at 2 wks, 6 wks, 3 mo, 6 mo, and 1 yr Stimulation/discover at around 2 wks Intercourse at 2 mo depending on healing Return to work 1-2 months depending Revisions if necessary at 6 mo to 1 yr 21 POTENTIAL COMPLICATION Neuropraxia UTI Bleeding Urethral stricture Wound dehiscence Incontinence Infection Vaginal prolapse Chronic pain Vaginal necrosis Blood clot Clitoral necrosis Rectal injury Vaginal stenosis Rectovaginal fistula Retained spongiosum Urinary retention regret 22 COMMON COMPLICATIONS- WOUND Dehiscence Mostly posterior incision line 23 COMMON COMPLICATIONS- WOUND Granulation tissue 24 PROCEDURES FOR TRANS MEN Chest affirming surgery Facial masculinization Body Contouring 25 26 27 28 29 PROCEDURES FOR TRANS WOMEN Facial Feminization Tracheal Shave Body Contouring Chest Affirming surgery Vaginoplasty 30 31 32 33 34 35 36 37 38 THANK YOU Contact information Palouse Surgeons/Linea Cosmetic Surgery Office 208.882.1700 Fax 208.882.1778 Website: lineacosmeticsurgery.com 39.
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