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 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 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 with antibacterial soap  Only use water based lubrication  Gently insert into the 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

 Neuropraxia  UTI  Bleeding  Urethral stricture  Wound dehiscence  Incontinence  Infection  Vaginal  Chronic pain  Vaginal necrosis  Blood clot  Clitoral necrosis  Rectal injury  Vaginal stenosis  Rectovaginal  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

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