Phalloplasty: Sensation & the Nerve Hook-Up

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Reader advisory: this week’s post talks frankly about the medical and physical aspects of sex, and the video contains diagrams illustrating these concepts. Discretion is advised.

A few weeks ago, we introduced you to free flap phalloplasty, which is one type of genital reconstruction (or “bottom surgery”) for transgender men and transmasculine folks. This week, we address one of the primary concerns raised by people considering this surgery: sensation and the ability to orgasm.

One of the most common misconceptions about trans male bottom surgery is that it results in a partial or total loss in sexual sensation. It’s not unusual to hear the sentiment, “I’d consider bottom surgery, but I don’t want to lose my ability to orgasm,” in trans male circles. In reality, free flap phalloplasty can include a nerve hook-up, a microsurgical technique in which nerves taken from another part of the body are attached to the clitoral nerve or other pelvic nerves and embedded into the new penis. This allows the patient to retain sexual sensation and function in the vast majority of cases. “In my experience, about 85% of free flap phalloplasty patients get erotic sensation, and 98% get tactile sensation,” says Dr. Curtis Crane. “And I’ve never had a patient lose the ability to orgasm.”

Although these numbers are promising, and certainly better than common bottom surgery lore, it’s important to remember that nerve regrowth is a slow, gradual process. Nerves must regrow through the axon sheath, and the rate at which this growth occurs is about 1 millimeter per day. At this rate, full sensation can take up to 2 years to reappear after surgery.

This video is captioned in English. To access the captions, click the CC button on the bottom right of the video.

FTM Top Surgery: The Periareolar Technique

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A few weeks ago, we posted about the double incision technique, a common top surgery procedure among trans men and transmasculine folks. This week, we bring you information on another kind of top surgery: the periareolar technique, presented by Dr. Scott Mosser.

First, we need to clarify our terminology a little bit. The procedure that trans folks often refer to as periareolar is more accurately called circumareolar. Within the trans community, periareolar usually refers to top surgery that’s performed by removing skin in a donut shape around the nipple, excavating the breast tissue, and pulling the skin together around the nipple like strings on a purse. Among plastic surgeons, the correct name for this type of surgery is the circumareolar technique, and is only one of many kinds of periareolar procedures (the keyhole technique, which we’ll discuss in a later post, is, medically speaking, another type of periareolar top surgery).

Dr. Mosser explains that, as with the double incision technique, there are pros and cons to choosing the cirumareolar procedure. “The upside of the circumareolar approach is…reduction of the incisions on the chest to just an incision that’s around the areola,” says Dr. Mosser, meaning that the scarring associated with the donut incision is far less obvious than that of the double incision approach. But, this reduced scarring can come at a cost. “You can imagine almost as if we were dealing with fabric, there would be a potential…to end up with a degree of pleating around the edges,” explains Dr. Mosser. By pleating, he means small folds in the skin, which protrude out in a starburst pattern from the nipple.

“In the absolute worst case, [a circumareolar result] can be converted to a double incision,” Dr. Mosser adds, meaning that a patient could potentially have their chest operated on a second time if they were not happy with their result. As more and more of us begin to rely on insurance to cover our surgeries, however, it’s important to note that insurance plans that would otherwise cover chest surgery may deny coverage for a revision.

We’ll continue to bring you information on even more FTM top surgery techniques in the coming weeks, including the keyhole and the T-anchor approaches.

Note: this video is captioned in English. To access the captions, click on the CC button in the bottom right on the video.

Phalloplasty: Choosing Your Donor Site

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For trans men, transmasculine folks, and others who were assigned female at birth, there are two major types of genital reconstruction or “bottom surgery”: metoidioplasty and phalloplasty. Metoidioplasty is a procedure that relies on the clitoral enlargement resulting from testosterone, in which the surgeon releases the ligaments around the clitoris, freeing it and bringing it forward to create a small phallus. In later blog posts, we’ll cover metoidioplasty, but today, we’re focusing on the second option: phalloplasty.

Phalloplasty comes in many different varieties, and can utilize different surgical techniques depending on the surgeon’s expertise and the patient’s preference. Today, Dr. Curtis Crane will introduce us to free flap phalloplasty. The term free flap means that the surgeon harvests tissue — skin, fat, arteries, veins, and nerves — from another part of the body, and creates a penis using that tissue.

The first decision a free flap phalloplasty patient must make is which donor site to use. “The most common donor sites are the forearm, the back, and the thigh,” explains Dr. Crane. “There are positives and negatives to each of these.”

Indeed, choosing the right donor site for you can be challenging. There are many factors to consider, including the number of individual surgeries (referred to as stages in the video), the location of the donor site scar, the aesthetics of the resulting penis, and the amount of sensation typically expected from a donor site. In this video, Dr. Crane gives a detailed description of each of the three major donor sites, and discusses the pros and cons of each. “Really take some time and think about this,” he says. “This is the phallus you’re going to have for the rest of your life.”

Keep an eye out for more great information on phalloplasty from Informing Consent with Dr. Curtis Crane in the near future.

Note: this video is captioned in English. To access the captions, click the CC button on the bottom right of the video.

FTM Top Surgery: The Double Incision Procedure

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For many trans men and transmasculine people, the double mastectomy procedure (better known as “top surgery”) is a vital part of medical transition. In addition to relieving dysphoria related to the chest, top surgery can also ease the difficulty of accessing spaces such as locker rooms, swimming pools, and beaches.

There are many different types of top surgery, but the most common is known as the double incision procedure. Today, Dr. Scott Mosser discusses the mechanics of this procedure as well as its pros and cons. “The downside of the double incision procedure is the visible scarring which is persistent after surgery,” explains Dr. Mosser. And although scarring is a concern for many people who access top surgery, double incision has some big upsides as well.

One significant advantage of DI is that virtually all patients are candidates for DI, whereas other procedures such as keyhole or periareolar are only available to patients with certain chest shapes and sizes. Second, according to Dr. Mosser, “[Double incision gives] the surgeon by far the best command control of the overall flatness of the chest. … It’s also the best control the surgeon has over placing the nipples,” meaning that double incision tends to produce the best results in terms of obtaining a flat chest and correctly sized and placed nipples.

Informing Consent and Dr. Mosser will bring you more information on top surgery in the near future, including videos on other techniques, such as the keyhole, the T-anchor, and the circumareolar procedures.

Note: this video is captioned in English. To access the captions, click the CC button on the bottom left of the video.

Informing Consent: Empowering Trans Folks through Information

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Five years ago, I was lying in a hospital bed, excited and nervous for my life to change for the better. I was two years into my transition from female to male, and I was about to get top surgery. My mind bubbled with fantasies of shirtless adventures in my near future. I’d lie on the beach with my friends, carefree as the sun beat down on my bare chest. I’d strip off my tank top in a gay bar, tuck it casually into the waist of my pants, and a hot man would buy me a drink, seeing me as my true gender. Life was going to be so much better.

It didn’t turn out so well.

I’d chosen to have the periareolar (more correctly called the “circumareolar”) procedure, a tricky surgery in which a donut of skin is removed, leaving a scar only around the nipple itself. I was drawn in by the surgeon’s promise that I’d maintain nipple sensation and have no noticeable scarring. What I didn’t know was that few trans men are good candidates for this procedure, and my surgeon didn’t know how to correctly judge my candidacy. My chest was too large, and I had too much extra skin. As a result, my incisions split open, became infected, and my chest had a lumpy, strange contour that looked wholly unnatural. It wasn’t at all what I’d imagined.

My original surgeon attempted to revise my result with two follow-up surgeries, neither of which improved things much. Finally, I lost faith in him, and sought the opinion of Dr. Michael Brownstein, a well-known and highly respected top surgeon. From him, I learned that I never should have undergone the peri procedure; double incision was a far better choice for me. He performed this procedure on me, resulting, finally, after more than two years, thousands of dollars, and four surgeries, in the chest I’d dreamed of.

Certainly, part of my bad experience with top surgery was because I didn’t see enough doctors beforehand. I was a student at the time, and although my university insurance covered a large percent of the cost of surgery, I didn’t have the luxury to travel around the country consulting with lots of surgeons. But in this day and age of digital information, there is no reason that I, or any trans person, should have to rely on in-person consultations to glean the necessary information about medical transition.

Transitioning should be easier, in all regards. Our medical options should not be mysterious. We should no longer need to rely on the limited information available from local doctors and our local trans communities. And with more and more doctors implementing the forward-thinking “informed consent” model of care, the onus is on us to educate ourselves. To do that, we need resources. We need reliable sources of information.

And this is the impetus for Informing Consent. We partner with surgeons who are regarded as experts in their fields and asked them to discuss, on video, the medical procedures that are essential (for some of us) to making our lives worth living. Over the next few months, we will release videos weekly, presenting information on Facial Feminization Surgery with Dr. Thomas Satterwhite, Phalloplasty with Dr. Curtis Crane, and FTM Top Surgery with Dr. Scott Mosser. Eventually, we will have information on other procedures as well, including vaginoplasty, metoidioplasty, breast augmentation, hysterectomy, and others.

We also know that surgery is not the only topic trans folks need information on. In addition to surgical videos, we’re working hard on tutorials on changing your name and gender on essential documents such as your driver’s license, passport, birth certificate, and social security card.

This Monday, August 3, 2015, we’ll officially launch with an overview of Facial Feminization Surgery presented by Dr. Thomas Satterwhite. Stay tuned, follow our blog, and keep up with us on Facebook or Twitter.