Pre and Post Operative Care for the Transgender 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 Gender 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) - Metoidioplasty +/- Urethral Extension +/- Scrotoplasty - Phalloplasty 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!” • (Intersex 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 penis is dissected to form functional neo-clitoris (functional = orgasmic) • Urethra 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 vaginectomy (closure) • Scrotoplasty from labia majora • 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 Erections: 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? • Orgasm ‘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 vagina 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.