Adam's apple shaving or chondrolaryngoplasty is aimed at correcting an unpleasant bulge at the anterior neck. This minor procedure can be done under local anaesthesia through a convenient skin crease and leaves a short horizontal and conciliable scar at the anterior neck. If desired, it can be combined with vaginoplasty and/or breast augmentation under general anaesthesia.
In the long term, it will not modify adversely your voice tonality and the unwanted "apple" will not grow back. In a short operative time, between 30 and 45 minutes, you can get rid of a constant embarrassment and your neck will fit your individual gender.
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Breast augmentation is often requested to enforce one's perception of feminine gender and give a well-proportioned figure. It is performed, most of the time, in combination with another procedure. For example, breast augmentation can be combined with vaginoplasty and/or Adam's apple shaving and/or rhinoplasty. It adds approximately 60 minutes to the operating time. It can also be done as a separate procedure.
To achieve chest fullness, saline filled implants are inserted under your existing breast. Being used since the 70's, they have a long history of safety and their reliability has increased to a very acceptable level.
1. Breast augmentation incisions, only one per breast is necessary.
2. Insertion of the breast implant increases breast volume.
The location of incisions, volume of augmentation, location of implants, either subglandular or submuscular, are some of the important points that have to be discussed with your surgeon. He will take into account your particular needs and goals, individual features and anatomy.
If you consider breast augmentation, you should ask for more information.
Consult ASPRS Patient Education Brochure at www.plasticsurgery.org/surgery/brstaugm.htm
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The fundamental frequency or pitch is the quality of voice that can be modified with surgery. Vocal register, intensity and vocal tract resonance eg vowel production) also can be changed but only with speech therapy.
The mechanical properties of the vocal cords have to be altered to modify pitch. This can be done directly by scarring procedures on the cords, laser and cauterization, but they are unpredictable, irreversible and often need revisions. On the other hand, it can be done safely by indirect cricothyroid approximation.
Cricothyroid approximation increases the tension in the vocal cords and consequently raises frequency from a male pattern of 100-150 Hz to a female one of 200-300 Hz. Preferably, the procedure is done under local anesthesia through a short neck incision and can be combined with Adam's apple shaving if desired. It requires a short operation time, one hour, during which you will notice an immediate change. Voice rest is recommended after surgery for a short period and the final result comes gradually within the first six to 12 months. Speech therapy is advised before and after surgery.
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Depending on what is done, the operation can last anywhere from three to five hours. If you are having additional work such as a skin graft, more time is required. Different surgeons perform the procedures differently.
Dr. Schrang You must understand a basic, fundamental problem regarding the final depth of your new vagina. I try to make the neo-vagina as deep as I can, up to six or seven inches is common, and obviously, the longer your penis, the more skin will be available to line this newly created opening. If future sexual intercourse is in your plans and your penile length is adequate, the standard genital procedure without a skin graft would be done. On the other hand, if your penis has relatively little length, I would suggest that a skin graft be used to help make the vagina deeper, unless of course, you have no plans for future intercourse. Full-thickness grafts are usually taken from the right and left sides of the abdomen which leave line scars that look like hernia repair scars. A split-thickness skin graft can be taken from the area beneath the umbilicus and above the pubic hair or it can be taken from the thigh or buttocks. In selected cases, Laser technology can remove hair from the scrotal skin which can then be used as a source of skin graft material which obviously avoids abdominal scars. A physical examination will determine whether or not a skin graft will be necessary. In general, the shorter your penis and the greater your desire for future intercourse, the more likely a skin graft will be considered. If you have a relatively short penis and insist on GRS without a skin graft, the inadequate depth of your vagina for future intercourse must of necessity be your responsibility.
Regarding Secondary Genital surgery to correct problems from a previous operation; experience has taught us that Sex Reassignment Surgery to correct cosmetic or functional problems occurring at the time of or after the first surgery are far more difficult the second time it is done because distorted anatomy and scar tissue interfere with meticulous surgical dissection. Complications such as operative and post-operative bleeding are more common and patient stay in the hospital can be prolonged over the usual 8 days. For these reasons, the surgical fee for an GRS redo is $8100.00. The hospital and anesthesia fees will remain the same as primary GRS, however there may also increased or added hospital, anesthesia and surgical charges if complications arise necessitating more surgery or if the eight day stay is exceeded. Any additional charges will be the patient's responsibility, so please come prepared to pay these extra costs at the time of your discharge. I will continue to be responsible for my own patients and will do whatever I can to improve upon any complications that may have arisen from surgery that I have performed. This however, does not make the degree of difficulty of any additional procedure less, but I would prefer that other surgeons deal with their own complications. Also, keep in mind that my labiaplasty is designed to compliment my GRS, if I am asked to do a labiaplasty on some other surgeon's GRS, an added $1,000 will be charged because experience has again taught us that much more must be done because so often the GRS has been inadequately performed, the clitoris has not been constructed or the urethra is poorly positioned, etc.
The question of secondary scarring from the skin graft donor site is always raised. Yes, there is a mark where the skin graft is removed. The colour of this area varies in intensity from person to person and in some patients it can become red, raised and last a long time. Although it invariably fades out in time, this involution process can be hastened by applying sheets of silicone to the area for several months. Again, the response of this new technology varies from patient to patient.
We expect our results to be good to excellent; However, complications can occur. Although most problems can be readily and successfully dealt with, the recto-vaginal fistula is the most serious possible problem that could happen. Should the rectum be inadvertently entered, the opening would be closed, but a future fistula could result. Your bowels are cleansed thoroughly before surgery to help prevent this problem but if a fistula does form, it would be necessary to do a temporary diverting colostomy until the fistula could be adequately closed at a later date. Keep in mind that the dissection of the neovagina is delicate and hazardous with the possibility of rectal damage always present.
I want to emphasize as strongly as I can that the first surgeon to do the GRS with or without a skin graft has the best chance for success. Experience has taught us that redo's to deepen the vagina can be but are not necessarily very difficult and run the risk of being unsuccessful. The rectum could be entered due to the fact that scar is present in the deep vagina making secondary dissection perilous. Once the secondary dissection is complete, a skin graft must be used to line the newly created, deep vaginal area which had previously contracted. This newly created opening has the tendency and great ability to contract again and obliterate itself in spite of diligent dilating on the part of the patient resulting in nothing gained. Therefore, we suggest for anyone who has had GRS done elsewhere and develops a vaginal contracture that they return to their original surgeon for treatment.
Since the operation cannot be performed completely in one stage, some patients elect to have the labiaplasty portion done three months later. This is intended to feminize the operated area and cannot be done at the time of the GRS because important blood supply would be cut off to vital tissue. Whether or not to have the Labiaplasty is your option.
Dr. Meltzer I use the penile inversion technique for vaginoplasty. This surgery is done under general or spinal anaesthesia. I remove the testicles and the erectile tissue of the penis. The vaginal space is created below the urethra, urinary tube. The penile skin is used to reline the vaginal vault, which eliminates the need for skin grafts in most cases. In patients with a shorter penis, less than 5" erect when measuring from the underside, distant grafts may still be avoided if the scrotum is cleared of hair preoperatively. The clitoris is formed from the glans of the penis keeping the nerves that supply it intact. By doing this, I can create a sensate clitoris and labia. A small portion of scrotum is used to fashion the labia, the lips of the vagina. A cotton stent is placed in the vagina, which stays six days. After the stent is removed from the vagina, it is necessary to start gently dilating the vagina four times a day for the first month. One needs to gently dilate the vagina after surgery or otherwise it will narrow and collapse. This will become less frequent over time, particularly if one becomes sexually active. For intercourse, the vagina will need some form of lubrication since it is lined with skin and lacks cells that secrete. It will also be necessary to douche on a regular basis in order to keep the vagina clean. A urinary catheter will be left in the bladder for eight days. After the catheter is removed, one will be able to urinate while sitting. After the swelling resolves the aesthetic results are quite nice and, in fact, I can usually create a very normal appearing vagina in one stage. A secondary labiaplasty is recommended, though not required, at least three months after the vaginoplasty. The purpose of the labiaplasty is to create a thinner inner labia, to provide some hooding to the clitoris, and to improve the overall aesthetic result. Not all patients will find this necessary.
Following surgery you will stay in the hospital for three days and will need to remain in the area for another seven days, total stay in Portland is 11 days. Should you prefer, you can remain in the hospital in the VIP rooms following discharge. These are special rooms that the hospital has provided, at a significant cost reduction, where patients may stay for the remainder of their stay in Portland. In the VIP rooms, nursing assistance and meals are provided. If you prefer to be out of the hospital, there are several reasonable hotels close by. If you do choose to stay in a hotel or at home, you should have a friend or family member who can help you with your care.
Certainly these procedures are not without risk, and I wanted to review these for you. Bleeding is a risk of any operation, particularly in the pelvis, though fortunately, I have never had to transfuse anyone. If you are particularly concerned about a transfusion, then I think it is prudent to give a unit of your own blood in advance. Infection is also a standard risk, but is very unusual. Occasionally, a minor revision of the labia or urethra is needed. These can frequently be done at the time of labiaplasty or in my office. The complication that concerns me most is creating an abnormal path between the rectum and vagina, called a rectovaginal fistula. Should this occur, it is possible that one would have both gas and faeces come through the vagina. In order to reliably close this communication a temporary colostomy would be required. A secondary operation can close the colostomy three months later. In my own practice, this has been an very rare complication, less than 1%, though it is the one I worry most about because of its implications. An abnormal communication between the urethra and vagina is also possible but in my experience, even more rare. All patients will be able to urinate while sitting; however, it is not unusual to have spraying of the urine until the swelling resolves. Though it is very uncommon, there have been reports of nerve injury in the legs or injury to the muscles, compartment syndrome, associated with positioning of the patient at the time of gynaecologic or urologic procedure. If a compartment syndrome of the leg occurs, then the muscles must be surgically released. This is a very unusual complication that we take every precaution to prevent with padding of the legs and careful positioning in surgery.
Dr. Meynard Dr. Meynard's refinements of the skin inversion technique has redefined the standards of vaginoplasty and are responsible for the most enviable reputation of Montreal as one of the world's best centres for GRS. Cosmetic and functional results are outstanding and state-of-the-art: skin hooding (prepuce) over the clitoris, excellent vaginal depth, vaginal opening with labia minora and without late contractures (posterior band).
After surgery you will be shown how to achieve dilation and proper hygiene. The vaginoplasty is a two and a half hour procedure under general anaesthesia. If desired, breast augmentation and/or Adam's apple shaving can be combined to your vaginoplasty.
Oliver M. Fenton Uses the "penile inversion" technique, but prefers not to use scrotal tissue inside the neovagina, because of the problems caused by hair. He prefers, where extra skin is required, to use grafts, usually taken from the buttocks. There will be some scarring at the donor-site. He uses the scrotal tissue to create labia majora.
Mr Fenton usually performs a "two-stage" operation. The first stage is the major part, consisting of the removal of the testes, penile inversion, construction of the neovagina and clitoroplasty. The "clitoris" is formed from glandular tissue, with nerves and blood-supply attached therefore retaining some sensitivity. A clitoral hood can be created from the remaining foreskin, although he reports that this "doesn't tend to look terribly realistic". The second stage is a usually minor "revision" where tidying-up occurs.
He sometimes performs a "colovaginaplasty", where part of the sigmoid colon is used to increase the depth of the vagina. However, there can be problems associated with this technique, fistulas etc, and he therefore only uses it where there are no alternatives.
Michel Seghers For male to female reassignment surgery, I use the penileskin inversion technique with the help of a long perineal flap based posteriorly. A clitoris is made of the base of both corpus cavernosum with a long portion of the dorsal neurovascular bundle.
If the original penis is short and circumcised, stretching exercises should be done in preparation for surgery. Since part of the perinealskin is used to line the posterior wall of the new vagina, hair removal by electrolysis is also advocated in advance.
Complications are possible such as bleeding (blood transfusion in rare cases), too short a vagina due to the initial short penis (circumcision or earlier orchiectomy are not advised, this would require the additional skin graft or better an intestinal flap), stenosis of the urinary meatus (requiring dilations or very rarely revision).
Tracheal shave can be combined with the GRS.
The anterior ends of the labia majora are too separated and sometimes perfectionist patients ask for a revision which gives a fantastic improvement in appearance (labioplasty with two large Zs).
This labioplasty can be done six months or more after the main surgery and can be combined with other refinements such as tracheal shave or breast enlargement.
In 1968 Jones, Schrimer and Hoopes described an operative procedure for construction of the external genitalia in male-to-female transsexuals. With minor alteration this method is commonly used today.
After castration, removal of the corpora cavernosa and amputation of the distal part of the corpus spongiosum urethrae together with the glans penis, skin of the penis, scrotum and perineum is used to line the neovagina and construct the labia majora.
In this method there is no constriction of a clitoris.
Although the clitoris is absent, a certain percentage of patients describe some degree of sexual satisfaction. In our opinion, this is only imaginary. A true orgasm after amputation of the glans penis is not possible.
The first successful case of the construction of a clitoris utilizing the glans penis was described by Rubin in 1980, (embrolyologically the clitoris and the glans penis are analogue structures, so the mutual substitution seems logical).
Rubin extirpated the corpora cavernosa, but did not amputate the distal part of the corpus spongosum urethrae and the glans penis, those he placed in the anterior wall of the neovagina as the neoclitoris.
The external urethral orifice was formed by a stoma proximal to the glans. In the second stage, Rubin closed the urethra distal to the stoma to prevent urinating through the formal male orificum. The glans penis can be regarded in this case as an island flap, fed by the "urethral arteries. The venous return occurs through the caverns of the corpus spongiosum urethrae to the vena bulbi.
We modified Rubin's original procedure in the late 80's in order to simplify it and to enhance the safety of the cirulation of the glans penis. The stoma was not created but kept the former male external urethrae orifice. Using this method, the second stage of the operation was avoided as was further damage to the vascular pedicle. Even with these precautions, the cirulation of the glans proved to be so sensitive that it often resulted in venous congestion in the glans during the first post-operative days, which had to be treated with multiple incisions. The glans healed with some major marginal necrosis. Not satisfed with the safety of this method, we looked for further improvements in the procedure.
Reviewing the anatomy, it was concluded that the primary blood supply to the glans penis is via the dorsal arteries and vein of the penis.
Castration and extirpation of the corpora cavernosa are performed through a 10 cm long vertical incision in the scrotal raphe.
The neovagina is lined by the penile skin. The labia majora is constructed by utilizing the proximal part of the scrotal skin; its major distal part is discarded. An important goal of this technique is to retain the entire corpus spongiosum urethrae and the glans penis.
This part of the operation begins with creation of the neurovascular pedicle of the glans by detaching the deep penile fascia (Buck's fascia), which contains the dorsal vessels and nerves of the penis, from the tunica albuginea of the corpora cavernosa by a proximal to distal dissection.
After having detached the fascia in its entire length, the entire spongiosum urethrae is carefully removed from the corpora cavernosa which, as mentioned above, will be extirpated.
Under the pubic bone in the future position of the female orifice externum urethrae, the penile skin is split longitudinally and the glans penis is inset. The longer male urethra and the fascia profunda penis containing the neurovascular pedicle is placed with a slight curve in the left labia majus. In order not to obtain an unnaturally large clitoris, the size of the glans should be reduced prior to final suturing and de-epithelializing its dorsal surface and resecting its nonsensitive circumference.
The penis is wrapped in two fascial layers; the superficial penile fascia, which is loosely connected with the skin, and beneath it, the deep fascia, which is tightly attached to the corpora cavernosa (Buck's fascia). In this fascia run the main vessels to the glans penis; in the middle and more superficially, the dorsal vein of the penis; parallel to it, the dorsal arteries of the penis, accompanied by the dorsal penile nerves, originating from the pudendal nerve and giving terminal branches to the glans penis.
The small urethral arteries running inside the corpus spongiosum urethrae and the venous return through them do not provide adequate circulation for the glans penis.
From 1989 until 1991, we performed nine cases (ages 21-29, with an average age of 25 years) of operative sex conversion in male transsexuals,
retaining the glans penis and converting it into a neoclitoris by creating neurovascular pedicle as described above. Utilizing this technique, no venous stasis, necrosis or any other circulatory complications were observed.
With this technique, the innervation of the glans remains intact. Our experience shows that patients respond sexually to erotic stimulation and manipulation of the neoclitoris even a short time after the operation.
In three cases, minor secondary corrections were performed. In one case, the size of the neoclitoris was reduced. In two cases, a proximal displacement of the neoclitoris toward the neovagina was necessary.
Mr.Terry Genital reassignment surgery can be done using a technique developed mainly at the Charing Cross Hospital in which total penectomy and bilateral orchidectomy are carried out and the scrotal flap is used together with penile skin to create a neovagina. Incorporating a technique he learnt in Holland it is possible to conserve part of the glans penis to make a clitoris. The clitoris works well in about 50% of patients but in some patients they have a very heightened sensation, so much so that in some cases it is necessary to remove the clitoris at a subsequent operation because of over stimulation.
All of these procedures are performed at the same operation and subsequently all that remains is for the patient to keep the neovagina patent by vaginal dilatation on a regular basis.
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Last Modified 25 Aug 2001