Pre and Post Operative Care for the Adult

© Linda Gromko, MD Swedish Transgender Conference Seattle, Washington – April 2018

1 In 1998, a caller asked: “Does your clinic treat transgender women?”

My answer: “Not yet…”

2 Twenty Years of On-the-Job Training

• Now, I’m the PCP for trans patients ages 5-85 • Hormones, puberty blockers & primary care • Trans-focused aesthetics • Pre and Post Operative Care in Confirming Surgeries

3 Today’s Agenda (Swedish Conference to Cover Sections 1, 3, 4)

1. Why Pre and Post Operative Care Matters (!) 2. Overview of Gender Confirming Surgeries Feminizing Surgeries: - FFS - Breast Augmentation - Vaginoplasty Masculinizing Surgeries Gender-affirming Chest Reconstruction (Top Surgery) - +/- Urethral Extension +/- - 3. Pre Operative Planning 4. Post Operative Evaluation: When to Reassure, When to Worry, When to Refer

(Both Pre and Post Care will Focus on Genital Surgeries)

4 1. Pre and Post GCS Care Matters!

• Many of our patients have moved the earth to get this care • They undergo insurance frustrations and financial risk • Seattle clients frequently travel out of town – even internationally – to have surgeries performed • Our patients are at once elated and afraid – because bad things can happen • Support is variable. (Is there a need for GCS “doulas?”) • You get more general sympathy and understanding with a cast! • But there are many things a person or a team can do to make this experience better. (For the purpose of this session, our pre and post op care will focus on genital surgeries.)

5 Section 2:

A Brief Overview of Feminizing Surgeries

6 FFS – Can you spot the changes?

• Brow shave to reduce frontal bossing • Scalp advance • Cheek implants • Rhinoplasty • Lip lift (reduces philtrum length) • Jaw Contour • Tracheal shave Can be the most difficult surgery from recovery standpoint!

7 Skull Differences Explain the Basics of FFS (Ousterhout slide)

8 Augmentation Mammoplasty (Mangubat slide)

• Note breast development from estradiol +/- progesterone Note breast development from • estradiolBreast +/ size- progesterone and nipple Breastplacement size and mustnipple balanceplacement out must balance out natal male shoulders natal male shoulders Silicone vs. Saline • ImplantsSilicone placed vs. overSaline or under pectoralis muscle • RecoveryImplants tend placed to be more over or under straightforward.pectoralis muscle development from • Recovery tend to be more straightforward.

9 Going Back to the Basics of Embryology (Netter illustration)

• We ALL start out with the same raw materials • Changes occur under the influence of testosterone from fetus • As Dr. Meltzer says, “It’s color coded!” • ( conditions excluded here)

10 GRS Techniques in MTF (Bowers slide)

11 How does this work? Check out YouTube for “Animated Transgender Surgeries!”

• Testicles removed from scrotum • Glans is dissected to form functional neo- (functional = orgasmic) • is dissected apart from glans penis and moved south • Corpora cavernosa go away • Penile skin is inverted and placed into neovagina created between urethra and rectum (perineum) • May be one-stage or two-stage process (labiaplasty is done about 3 months later) • Surgery using sigmoid colon usually reserved for “salvage” procedures in the US In my personal slides, I do not identify patients or surgeons. My patients have consented to use of photos.

12 Section 2:

Now, let’s switch to masculinizing surgeries.

13 Masculinizing Chest Surgery Creates the Look of a Male Chest vs Reduction Mammoplasty (Mangubat slide)

• No more binders! • Double incision (illustrated here) vs. keyhole procedure for smaller breasts • Note nipples are made smaller • Top surgery is intended to create male chest - not to remove every breast cell! (Think breast cancer screening)

14 Remind ourselves of the basics – and goals:

What is important to patient? • Clitoral enlargement from testosterone can be significant • Does the patient want to have the phallus look more like a penis? • Does he want to urinate standing up? • Does he want to be able to penetrate a partner during sex?

15 If the “look” of the penis is the goal, consider metoidioplasty (can be combined with later surgeries) (Crane slide)

• Also called “clitoral release” in that inferior ligaments to clitoris are severed, making the phallus protrude more • Penis pumps can enlarge phallus, and some men are able to penetrate partners. • Many have had hysterectomy/BSO • Would still pee sitting down – unless patient has urethral extension using vaginal or buccal mucosa to lengthen and relocate urethra

16 Here’s an example of metoidioplasty, urethral extension & scrotoplasty with implants (Crane slide)

• Clitoral release • Urethral extension using vaginal or buccal tissue (The longer the extension, the more likelihood of urethral stricture/narrowing) • Maybe (closure) • Scrotoplasty from • Tissue expansion and insertion of scrotal prostheses

17 If a man wants to – pee standing up and to be able to penetrate a partner, phalloplasty is advised. (Crane slide) • Complex, several surgeries to complete • Donor site for phallus is radial forearm, anterior lateral thigh, or latissimus dorsi • Scarring from donor site is significant; urethral strictures and fistulae are possible • Size of penis depends on donor site (anterior lateral thigh is large) • Note glansplasty here

18 Donor Site Examples

19 Stand to Pee Three Weeks After Phalloplasty (Crane slide)

20 Common General Steps in Phalloplasty: Don’t forget to check out YouTube) (Crane slide) • Hysterectomy and bilateral salpingo-oophorectomy • Metoidioplasty • Urethral Extension • Scrotoplasty with implants • +/- Vaginectomy • Phalloplasty • Glansplasty

21 Two Methods for :

1. Insertion of a penile pump inside the neo-phallus as is done for natal males with E.D. – Pump mechanism is placed within the neo-scrotum on one side – Testicular implant on the other side of scrotum 2. Malleable rod implanted in the neo-phallus – Placed 8-9 months after phalloplasty to avoid penetration injury – Never flaccid: always erect or semi-rigid

22 But what about sexual response?

• ‘originates’ from the clitoris – either positioned under the phallus, or tucked inside it • Does ejaculation occur? – Not as we tend to think of it – No prostatic fluid or seminal vesicles – And, of course, no sperm • Remember glans penis becomes neo-clitoris for trans females!

23 Section 3: Preparation for Surgery: 1 Year in Advance

• Are ongoing medical issues addressed? (weight loss, DM, etc.) • Allow a year for pre operative hair removal: laser/electrolysis • Letters from all required? (Genital: usually Master’s level and MD/PhD and often hormone prescriber) • Stop smoking!

24 More Pre Operative Issues

• Is the surgery planned the right one for that particular patient? • Does the patient understand the surgery? • When do we stop pre operative hormones? • What if the patient is normally on anticoagulants? (Ask your hematologist) • What about other meds? (e.g. ASA, Vitamin E) • Are travel plans firmed up? Appropriate Documentation? • Is your patient at risk for depression? Think ahead; prescribe ahead.

25 Plan Ahead for Post Operative Nutrition

• Barring renal disease, estimate 1.2-2 gm protein per kg body wt For 70 kg (150 lb) human, up to 140 gm protein/day. (Think chicken, meat, fish, tofu, eggs, whey/pea protein in smoothies) • Fluids are encouraged for general healing AND urinary tract function • Vitamin C • Fiber to avoid constipation with narcotic pain medications • Consider grocery delivery

26 Basic Smoothie Recipe

Blend in blender capable of crushing ice: • 1 banana • 1 scoop whey, soy or pea protein • 1-2 cups ice cubes • Add milk (dairy, almond, rice) to blender limit Add other fruits and greens as desired

27 Things to Have on Hand for Post Operative Recovery and Travel

• Neck cradle to sit on after genital surgery • Travel compression stockings at travel shops, airport • Blender for smoothies • Movies/audio books

28 Take a Page from Your OB Experience…

• Sterile lubricant for dilating • Extra pillows • Baby Wipes, extra wash cloths • Peri-bottle for rinsing perineum front to back • Easy clothing to wear • Sanitary protection (for both men and women)

29 Prepare Your Patient for Post Vaginoplasty Care

• Dilation as prescribed – If you don’t dilate, the neovagina closes! – Go down a size if you must; don’t stop dilating! • No speculum exams x 3 months • No penetrative IC (vaginal or anal) until surgeon clears

30 Learning to Urinate after Vaginoplasty!

• Urine stream is unpredictable: spray or stream going in various directions – often directed by swelling in labia • Instruct to wipe from front to back • UTIs: treat x 7-10 days rather than the 3-day abbreviated treatment • Get test of cure after treatment

31 Medications/Returning to Work

• Plan on return to work on Th/Fri after recovery • Always ask about depression • Adjust meds: – Stop spironolactone – May leave estradiol alone, or cut by about one third. Measure steady state level before dose # 6.

32 Section 4: Evaluating Your Patient Post Operatively (all patient photos from QAMA used with patient and consent, and surgeons will not be identified)

33 Q: “Does my look normal?” A: “YES!” (from Jamie McCartney’s Great Wall of Vagina)

34 Some examples: here’s a no-depth vagina

• If a woman isn’t planning on having penetrative sex, and she doesn’t want to dilate – • She may opt for no depth at all, a shallow depth, or a “dimple” • As the clitoris is intact, orgasmic function should be fine.

35 But the first two days I saw her, it looked like this (about 3 weeks after surgery):

36 From OB experience: “Leave both halves of the vagina in the same room and it will heal.”

37 Time, reassurance, patience, bupropion:

38 Patient is happy with outcome.

39 Bruising and perineal edema can be impressive! Watch for firm hematomas.

40 Two weeks later: swelling reduced on left. Note tracking of ecchymosis. Patient sleeps on her right.

41 Two more weeks of recovery, and sleeping on back:

42 “Slough” is adherent yellow material and is not infection. Granulation tissue is cherry red.

43 Treat granulation tissue with silver nitrate sticks. Will slough off as gray discharge in 2-3 days.

44 This is a 68 yo woman who went out of USA

• Age limit depends on overall health • Favorable surgical outcome, but while she was recovering, she learned that her wife had died back in Washington • Imagine making arrangements on the Internet for her wife’s remains – and coming home to the empty house.

45 This patient had labiaplasty – two step surgery.

46 Here’s an example of a graft site where more tissue was needed for vaginoplasty.

• Graft tissue was harvested at the level of the anterior superior iliac spine • Notice how it will blend into the skin lines on healing • We will likely see this more as younger patients with less developed genital tissue (puberty blockers) have genital confirmation surgery.

47 Four Weeks Post Vaginoplasty

48 Here’s a Bacitracin reaction! (Meltzer slide)

• Stop topical Bacitracin • Consider stopping all topicals • Switch to something without neomycin (like polysporin) • Other possibilities are metronidazole, or if an area looks like a burn: sulfadiazine cream

49 Turning to trans male genital surgeries…

• Again, it is critical to know what patient wants, i.e., improved appearance of penis, ability to stand to pee, penetration • Male genital confirmation surgeries may be divided into 3-4 separate surgeries • Cost is much higher, and insurance coverage more variable • Complications are, of course, infection, bleeding, damage to tissue, and urethral strictures/fistulae in urethral lengthening surgeries

50 This patient went out of country for metoidioplasty, scrotoplasty, and vaginectomy.

51 More time passes…

52 Pending issue is the positioning of the left prosthetic testis (? organizing hematoma below vs adherent scar tissue).

53 Scrotal midline is now a “seam.” Visualize left testicle in intended position.

54 This patient had metoidioplasty, urethral extension, and tissue expanders for scrotoplasty.

55 Impressive edema subsides; pt begins to instill tissue expanders with normal saline.

56 Tissue expanders are “place holders” for scrotal prostheses.

(Different patient, s/p phalloplasty)

57 Nearly one year after multiple surgeries, urethral stenosis is ongoing issue.

58 PCP may need to help post operative male by:

• Removing a suprapubic catheter from a post operatively • Removing drains from monsplasty (always longer than you’d think!) • Assisting with catheterization • Assisting with dilation of urethra with surgeon’s okay • Watch for UTIs and treat for longer duration; always get test of cure • Have a good trans-friendly urology referral in your pocket! • Sharing photos with patient’s surgeon for a consult • Remember that most health care providers are NOT familiar with these procedures, and the ER in a crisis isn’t the place to learn.

59 For ALL surgeries, remember the peri operative DVT or PE (even with Oxygen Saturation = 100%)

60 What can happen with a DVT?

• A clot forms—usually in the deep veins of legs or pelvis • Clot travels north • Veins get larger until… They reach the lungs! • There, vessels are tiny— and get blocked by clot • Outcome depends on size, but can be fatal.

61 Warning Signs for DVT/PE

DVT (Deep Vein Thrombosis) • PE (Pulmonary Embolism) • Swelling in leg • Pain at the “peak” of each breath • Tender lump in leg • Chest pain, arrhythmia • Tender “cord” in leg • Upper abdominal pain* • Tightness in one leg • Shortness of breath • Pain with walking because • Hemoptysis, cough of above • Dizziness/agitation/loss • Think history! of consciousness *Think gall bladder also!

62 Voice Surgery Pearl

• This patient went out of country for vocal cord shortening • Was told never to have an ET tube over 5.5 mm in diameter • Consider LMA (laryngeal mask anesthesia) for elective surgeries down the road • We discussed a Medic Alert Tag with intubation cautions.

63 Linda’s favorite post operative tips for PCPs:

• We are not surgeons – but don’t panic • We have many observational/clinical skills that will help • Common sense is rare in medicine – use it! • See your patient soon on their return after surgery • Always go back to these basics: – Are you eating? – Are you gradually getting better? – Any fever/teeth-chattering chills? – Do you feel you need to be in the hospital/ER right now? – Get meaningful labs – Trust your gut!

64 Post Operative Tips for PCPs, cont’d

• Abscesses may need to be drained; can be ultrasounded for better definition • An organizing hematoma may resolve • Use your smart phone to get a photo – and send photo to the surgeon for input • UTIs should be respected: treat longer (7-10 days) and get a test of cure. • If patient is slowing their urine stream – or not urinating - call your go-to trans-friendly urologist!

65 Can you help your patient with a script?

Your patient’s gender-related surgery is nobody’s business. But people can be inquisitive – and intrusive. Share what you want only with people you choose. Example: Pt after masculinizing surgery had to stay out of country longer than expected. • Pt was concerned that friends who knew nothing about the surgery would be asking for details. • “Oh, I had a bike accident while on vacation. Well, I don’t want to go into detail. But google up ‘Straddle Injury.” Is this a “lie,” or simply a way we can help our patients navigate unpredictable waters?

66 Thank you for your attention!

“Where’s MY Book?” A Guide for Transgender and Gender Non-Conforming Youth, Their Parents, & Everyone Else

Linda Gromko, MD [email protected] QueenAnneMedicalAssociates.com www.LindaGromkoMD.com (206) 281-7163

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