Metoidioplasty and Phalloplasty EXPLORING YOUR SURGICAL OPTIONS Objectives • REVIEW your surgical options • UNDERSTAND the objectives of genital surgeries • LEARN about prevention and treatment of possible complications Decision-Making Considerations for Genital Surgery Appearance • Length • Width • Donor Site Scar (phallo) Complications/Risks Function • Urethral Lengthening • Stand to pee • Graft (phallo) • Sexual • Flap (phallo) • Fertility • Implants • Unresolved dysphoria Genital Surgeries METOIDIOPLASTY PHALLOPLASTY o Surgery that reshapes and o Surgery that creates a new releases the existing phallus phallus from other tissue (donor site) Associated Surgeries o Urethral reconstruction o Removal of uterus, ovaries, and/or vaginal canal (vaginectomy) o Fertility preservation considerations – Ob/Gyn referral available, if interested o Creating a scrotal sac +/- implants o Penile implants (phalloplasty only) Urethral Reconstruction o The urethra is the tube that carries urine from the bladder to the outside of the body o Genital surgeries can include lengthening the urethra o from natal position to base of phallus o through the phallus Associated Surgeries Fallopian tube Vaginectomy o removal and closure of vagina Ovary Hysterectomy o Removal of the uterus Uterus Salpingo-Oophorectomy o Removal of fallopian tubes and ovaries Fertility and Hormone Considerations o Consultation with an Ob/Gyn for discussion If urethral lengthening: Associated Surgeries o Hysterectomy can be done separately, or combined with metoidioplasty or 1st stage of phalloplasty o In patients seeking urethral lengthening, vaginectomy is required Then vaginectomy and hysterectomy required: o If vaginectomy is planned, hysterectomy is required o Oopherectomy is not required for any genital surgeries Metoidioplasty Overview Metoidioplasty Defined Goal Use existing genital tissue to create a more o cylindrical shaft appearance for the phallus Technique Phallus (clitoris) is released from surrounding o ligaments and skin Phallus is reshaped to make it more prominent; o phallus maintains current length and width o Preserve current sensation and nerves (no nerves are cut) Metoidioplasty: Testosterone and phallus length o Testosterone causes a variable amount of phallus (clitoris) growth o Maximum growth is usually achieved within 1-2 year after starting testosterone o Maximum growth from testosterone is usually 1-3 centimeters, but this is variable o Overall length of phallus after meta is determined by testosterone effect not by surgery Metoidioplasty Options: Meta without Urethral Lengthening What is meta without urethral lengthening? o Current phallus is released and shaped into a shaft o No routing of the urethra through phallus o Can include scrotoplasty, vaginectomy, and hysterectomy nd o Testicular implants placed in 2 outpatient surgery scheduled at least 3 months after initial surgery Metoidioplasty Options: Meta with Urethral Lengthening What is meta with urethral lengthening? o Current phallus is released and shaped into a shaft and urethra routed through phallus o Can include scrotoplasty, vaginectomy, and hysterectomy nd o Testicular implants placed in 2 outpatient surgery scheduled 3 months after initial surgery Metoidioplasty Considerations META WITHOUT URETHRAL LENGTHENING META WITH URETHRAL LENGTHENING o Least time in the operating room o Less time in operating room than of genital surgery options phalloplasty o Shortest recovery time of genital o Urethral surgery increases surgery options chances of urinary complications No change in urination (ie, o o Standing to urinate is a goal, standing to urinate is not a goal) more likely if BMI is normal and phallus protrudes beyond surrounding tissue Phalloplasty Overview Phalloplasty Staging Phalloplasty is a series of surgeries o The number of surgeries depends on surgical goals and donor site, with the possibility of more surgeries if complications arise o Total surgery timeline depends on recovery process; can be up to 1-3 years before all surgeries are complete o Important to consider time off work required, multiple hospital stays, financial needs Sample Surgical Staging Pathway Radial Forearm Flap (Double Tube) with Urethral Lengthening Stage 1 (Plastic Surgeons, Gynecologist, Urogynecologist) 1) Vaginectomy / hysterectomy / +/- salpingo-oophorectomy 2) Glans/shaft release (similar to meta) (Approximately 6 weeks after Stage 1 + 2) 3) +/- Scrotoplasty Post-Op Check (Urologist) 4) Local Urethral Lengthening 1) VCUG (urinary xray) 5) Suprapubic Catheter 2) Removal of Suprapubic Catheter (Wait at least 3 months for healing) (May be repeated) Stage 2 1) Phallus construction (flap) with new urethra tube inside 2) Glansplasty 3) Suprapubic Catheter Stage 3 (Urologist) 1) Penile Implants 2) Scrotal Implants (Wait at least 9-12 months until implants) 3) +/- Glansplasty Sample Surgical Staging Pathway Anterior Lateral Thigh Flap (Single Tube) with Urethral Lengthening Stage 1 (Approximately 6 weeks after Stage 1 + 5) 1) Vaginectomy / hysterectomy / +/- salpingo-oophorectomy 2) Glans/shaft release (similar to meta) Post-Op Check (Urologist) 3) +/- Scrotoplasty 1) VCUG (urinary xray) 4) Local Urethral Lengthening (Suprapubic Catheter) 2) Removal of Suprapubic Catheter (May need to be repeated) Stage 2 Phallus construction (flap) as single tube Stage 3-4-5 (Wait at least 3 months for healing in Tubularization of Flap between each stage 1-5) Stage 5-6 1) Urinary hook up 2) Suprapubic Catheter 3) Glansplasty Stage 6-7 (Urologist) 1) Penile Implants (Wait at least 9-12 months for healing until implants) 2) Scrotal Implants Sample Surgical Staging Pathway Radial Forearm Flap or Anterior Lateral Thigh Flap (single tube) WITHOUT Full Urethral Lengthening Stage 1 (Approximately 6 weeks after Stage 1 + 2) 1) Vaginectomy / Hysterectomy / +/- salpingo-oophorectomy 2) Glans/shaft release (similar to meta) Post-Op Check (Urologist) 3) +/- Scrotoplasty 1) VCUG (urinary xray) 4) Local Urethral Lengthening 2) Removal of Suprapubic Catheter 5) Suprapubic Catheter Stage 2 1) Phallus construction (flap) as single tube 2) Urethra placed at base of phallus (or scrotum if present) Stage 3 (Urologist) 1) Penile Implants 2) Scrotal Implants Wait at least 9-12 months Phalloplasty without Urethral Lengthening Considerations: o Urinate from base of phallus or under scrotum; standing to urinate not possible o Fewer urinary complications Radial Forearm (RFA) Phalloplasty Flap removed from forearm Superficial Inner tube l Deep Thickness of Penis (Diameter) = -4 x flap thickness Drs. Lin and Safa, 2020 oBlood vessel test to ensure forearm is eligible donor site RFF Surgery Summary o Creating the flap from the forearm o Resurfacing the forearm with skin graft from the thigh o Transplanting the forearm flap to the groin o connecting vessels, nerves, and urethra RFF Healing Three healing sites: oForearm (Donor Site) o Skin graft covers part of forearm where flap came from oSkin graft donor site (usually upper thigh) o Heals over several months oPhallus o Expect swelling and bruising after surgery Forearm: Healing and Rehabilitation o Initial Skin Graft Healing o Wound vac for 1 week o Daily dressing changes o Splint for 1 month o Minimizing Edema o Postoperative swelling (edema) occurs as a result of the surgical flap harvest and reduction in drainage of the hand o Compression and Hand therapy to restore hand function o Final Cosmetic Result o Step off at juncture of skin graft is thinner than surrounding forearm Forearm: Healing and Rehabilitation Skin Graft Donor Site: Healing st o 1 Phase: Daily dressing change (4-6 weeks) nd o 2 Phase: Apply moisturizer and sunscreen 1st Phase: Hospital Recovery and Monitoring 5-7 days • Bedrest • Frequent blood vessel checks of flap 2nd Phase: Recovery at home First few months Phallus Healing • Limited mobilization • Elevation of phallus for first few months • Suprapubic Catheter in for about 2 months • Monitoring for urine leak and skin healing 3rd Phase: Monitor for Additional Revision After 3 months • Persistent urine leak • Glansplasty – initial or revision RFF Phalloplasty Results Glansplasty images from Journal of Sexual Medicine – Sommeling et al. RFF Images Copyrighted by Buncke Clinic Thigh Phalloplasty PEDICLED ANTEROLATERAL THIGH FLAP Thigh Phalloplasty: Pedicled ALT Flap Thigh Phalloplasty: Pedicled ALT Flap 1cm thick flap Single tube (no internal urethra) ALT Surgery Summary o Creating the flap from the thigh o Resurfacing the thigh with skin graft from the other thigh o Tunneling the thigh flap to the groin o connecting nerves and urethra (vessel stay attached) ALT Healing Three healing sites: o Thigh (Donor Site) o Skin graft covers part of thigh where flap came from o Skin graft donor site (usually upper thigh) o Heals over several months o Phallus oExpect swelling and bruising after surgery Thigh Flap Donor Site: Healing & Rehabilitation o Initial Flap Donor Site Healing o Wound vac for 1 week o Daily dressing changes o Minimizing Edema o Postoperative swelling (edema) occurs as a result of the surgical flap harvest and reduction in drainage of the leg o Compression and elevation to restore leg function o Final Cosmetic Result o Step off at juncture of skin graft is thinner than surrounding thigh Skin Graft Donor Site: Healing st o 1 Phase: Daily dressing change (4-6 weeks) nd o 2 Phase: Apply moisturizer and sunscreen 1st Phase: Hospital Recovery and Monitoring 5-7 days • Bedrest • Frequent blood vessel checks of flap 2nd Phase: Recovery at home ALT Phallus First few months