Transgender Patients - American College of Physicians

Surgical Options for the
Transgender Patient
Rachel Bluebond-Langner M.D.
Assistant Professor of Surgery, Division of Plastic Surgery
University of Maryland School of Medicine
Disclosure
• I have no corporate financial relationships and
have received no financial support in
gathering the information to be presented
Definitions
• Sex : biological term referring to genetics and
anatomy (were you born with male, female, or
indeterminate anatomy?)
• Gender Role: traditional behavioral differences
between men and women, as defined by the culture
in which they live
• Gender Identity: person’s internal or perceived sense
of their gender (do you feel like you are male or
female?)
www.fennwayihealhth.org
Definitions
• Transgender/Transsexuals: identify and/or express their gender as
the opposite of their biologic birth sex. Often seek hormonal and
surgical treatment.
• Intersex/Hermaphrodite: spectrum of conditions involving anomalies
of the sex chromosomes, gonads, reproductive ducts, and genitalia.
• Cross dresser/ Transvestite: enjoy wearing clothing commonly
associated with the opposite gender; a person who cross-dresses
does not always identify as having a gender different from that
assigned at birth
• Homosexual: sexual attraction to the same sex; NOT related to
gender identity
DSM V Definition of
Gender Identity Disorder
Gender Dysphoria
• people whose gender at birth is contrary to the one they identify with
• must continue for at least six months
• condition causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
• The DSM-5 diagnosis adds a post-transition specifier for people who
are living full-time as the desired gender (with or without legal
sanction of the gender change). This ensures treatment access for
individuals who continue to undergo hormone therapy, related
surgery, or psychotherapy or counseling to support their gender
transition.
• Gender dysphoria will have its own chapter in DSM-5 and will be
separated from Sexual Dysfunctions and Paraphilic Disorders.
ICD-10 Definition of Gender Dysphoria
(Gender Identity Disorder)
• A desire to live and be accepted as a member of the opposite
sex, usually accompanied by a sense of discomfort with, or
inappropriateness of, one's anatomic sex, and a wish to have
surgery and hormonal treatment to make one's body as
congruent as possible with one's preferred sex.
• The disorder is not a symptom of a mental disorder or
chromosomal abnormality
• ** Interestingly still classified under
– GenderIdentity Disorder
• Transexualism
Transgender Facts
• Number of Americans who identify as transgender still not clear.
– ???\country’s transgender population: 700,000, or 0.3 percent of adults
– (Figure comes from two surveys. Massachusetts in 2007 and 2009 and
California in 2003.
– government-funded population surveys ask for your gender. But the U.S.
Census, for example, allows for only two responses: male or female.
There’s no option for transgender individuals .
• Poverty is a massive problem in the trans community.
• In the District of Columbia, 42% of respondents were unemployed,
29% had no income and 31% had incomes of under $10,000/year
(source: Washington Transgender Needs Assessment Survey).
• 26% of transgender people have a hard time finding different places to
sleep at for short periods of time and 11% have been evicted at least
once.1
• In the District, 19% of transgender respondents do not have a living
space and 13% of those who have a living space do not feel safe in
their own home
Transgender Facts
• Negative outcomes of lower economic status:
– In the Washington Transgender Needs Assessment Survey, 47% of transgender
people reported not having health care insurance.
– Lack of financial means may lead to harmful self-treatment: 58% of
transgender people have acquired hormones from friends or on the street.
– A lower socio-economic status reduces access to information: 37% of
participants declared not knowing where to obtain trans-specific services and
less than 10% knew of the Benjamin Standards of Care4. Additionally, 25% of
those engaging in unsafe sexual behavior admitted they didn’t know there was
a risk associated with the behavior (source: WTNAS).
• Safety issues in public spaces:
– According to a survey carried out by DC Trans Coalition, 68% of transgender
people have been denied access to, verbally harassed in, and/or physically
assaulted in public bathrooms7.
– Transgender people are also more likely to have negative interactions with the
police because they “fit” the profile of sex workers: 33% of transgender
respondents declared fearing violence from the police8, and 75% reported
worse treatment and human rights violations while locked up9.
Transgender Facts
• Specific Health Concerns
• The transgender community is disproportionately affected by HIV/AIDS.
– 25% of transgender respondents reporting living with HIV. Male-to-female
people are even more at risk with a 32% rate (source: WTNAS).
– National HIV rates in the male-to-female population are more than 3 times
that for men who have sex with men (MSM), and sixty times of the general
population.2
• Transgender people struggle with accessing medical care:
– 39% do not have a physician for routine health care.
– While 52% of the respondents had taken hormones at some point in their
lives, 37% did not know where to obtain trans-related services (source:
WTNAS)
• The transgender population is more at risk in terms of mental health:
– 35% of the District’s respondents have experienced suicidal ideation, and
64% of them attributed it to gender identity issues (source: WTNAS)
– On average, 50% of the transgender community suffers from mental health
issues compared to 5% of the LGB community and 2% of the heterosexual
population.3
– Respectively 34 and 36% of transgender persons reported an alcohol or
drug abuse problem (source: WTNAS).
Steps in the Treatment Process
• Mental Health Assessment
• Real Life Experience
• Hormonal Therapy
• Surgical Treatment
• Continued Multidisciplinary Care
Steps in the Treatment Process
• Mental Health Assessment
• Real Life Experience
• Hormonal Therapy
• Surgical Treatment
• Continued Multidisciplinary Care
Hormone Therapy
• Overseen by an endocrinologist or PMD
• Two approaches
– Suppression of endogenous hormones
– Administration of exogenous hormones
• Variability in degree of expression desired
– Maximum expression
– Androgynous
Femminization Hormonal Therapy (MTF)
• Estrogen (oral or IM)
• Androgen antagonist to prevent male pattern hair loss
(spirinolactone or cyproterone actate)
• Most changes are reversible
• Fertility may be permanently affected
• PSA may be falsely low (Need for DRE)
Feminizing effects of Estrogen
(MTF)
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Redistribution of body fat
Decrease in muscle mass and strength
Softening of skin/decreased oiliness
Decreased libido
Decreased spontaneous erections
Male sexual dysfunction
Breast Enlargement
Decreased testicular volume
Decreased sperm production
Decreased body hair growth
Does not change voice
Hair loss stops
Masculinization Hormone Therapy
(FTM)
• Testosterone (oral IM transdermal)
• Antigonadotropic effect in high doses
• Voice and hair changes not reversible
• Fertility may be permanently affected
• Should use birth control until hysterectomy
Masculinizing Effects of Testosterone (FTM)
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Skin oiliness/acne
Facial/body hair growth
Scalp hair loss
Increased muscle mass/strength
Fat redistribution
Cessation of menses
Clitoral enlargement
Vaginal atrophy
Deepening of voice
www.villagevoice.com
Complications of Hormone Therapy
• Estrogen
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Thromboembolism
Elevated transaminases
Breast cancer risk
Coronary Artery disease
Cerebrovascular disease
• Testosterone
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Elevated transaminases
Erythrocytosis
Breast and uterine cancer
Decreased bone mineral density
Suggested Criteria for Surgery
• Persistent well documented gender dysphoria. Diagnostic
assessment by a mental health professional specializing in GID
• Real life experience ( 12 months for bottom surgery)
• Hormonal therapy (12 months for bottom surgery ; +/- for other
surgery)
• Letter from a mental health provider
1 for top surgery
2 for bottom surgery
• For bottom surgery patient must be over 18 years old
• Non smoker; Not obese; Co- morbidities under control
• For all surgeries patient should be under the care of
– Mental health provider
– Endocrinologist or Internist if on hormones
Choosing a Surgeon
• Demonstrated experience in Gender Reassignment Surgery
– A subcutaneous mastectomy for breast cancer is NOT the same as a
subcutaneous mastectomy for chest reconstruction in the female to
male patient!
• Board Certified
• Follows WPATH guidelines
Surgical Considerations &
Hormone Therapy
• Increased incidence of venous thromboembolism
with estrogen
• Increase incidence of hematoma with testosterone
(suppression of clotting factors II V VII X)
• Reduce dose by half 4 weeks before surgery and stop
2 weeks before surgery
Surgery for Affirmed Men
(Females to Males )
• Mastectomy
• Hysterectomy and oophorectomy
• Genital Reconstruction
– Phalloplasty
– Metoidioplasty
– Scrotoplasty
FEMALE TO MALE
MASTECTOMY
Mastectomy
• Mastectomy Techniques are similar to those used for
gynecomastia
– Periareolar +/- liposuction
– Mastectomy/double incision with nipple grafts
• Male nipples compared to female nipples are:
– Lower
– Lateral
– Small and oval (2.5x2.7)
Grade 1
Small breast
No skin redundancy
Technique - Periareolar
Grade 2A
Moderate breast size
No skin redundancy
Periareolar Technique
Periareolar Technique
Periareolar Technique
Technique - Periareolar
Grade 2B – ”Borderline”
Moderate breast size
WITH skin redundancy
Periareolar Technique
Inframammary fold/Double incision
Grade 3
Marked breast size
with marked skin redundancy
Inframammary Fold/Double incision
Inframammary Fold/Double Incision
Grade 4
Atrophic breast
with marked skin redundancy
Inframammary Fold/Double Incision
Periareolar Technique
(Grades 1, 2A, +/- 2B)
Periareolar Technique
Periareolar Technique
Inframammary fold/Double Incision
Technique
Inframammary fold/ Double incision
markings
Markings:
Nipples
lower
lateral
oval 2.5 x 2.7 cm
Prior Breast Reduction
Inframammary Fold/Double Incision
Complications - MASTECTOMY
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Hematoma – 5%
Seroma – 10%
Loss of Nipple – less than 1%
Areolar spreading (keyhole) – 30%
Nipple hypo/hyper-pigmentation (often temporary) – 22%
Skin excess (periareolar)
Design failure
Infection- less than 1%
Complications
Seroma – 10%
Complications
Hematoma – 5%
Complications
2 weeks post op
Partial graft necrosis is NORMAL
with free nipple grafts
Healed nipple grafts
Complications
Nipple Depigmentation
Complications
Skin excess (periareolar)
Complications: Skin excess (periareolar)
Complications
Design failure-Inadequate resection
Complications
Design failure- Inadequate resection, bilateral Nipple loss
Female to Male
Phalloplasty
Phalloplasty
• Techniques
– Pedicled
– Free
• Donor Sites
– Groin/Abdomen
– Radial Forearm Flap
– Myocutaneous Latissimus Dorsi Flap
– Osteocutaneous Fibula flap
– Anterior Lateral Thigh Flap
Goals of Phalloplasty
• Aesthetic
• Functional (ability to penetrate)
• Tactile and erogenous sensation
• Ability to urinate standing
• Minimal donor site morbidity
Stages of phalloplasty
• 1. Creation of the neophallus +/- urethral
reconstruction
• 2. Urethroplasty +/- testicular implants @3 mons
• 3. Insertion of penile prosthesis @ 1 year when
tactile sensation has returned
Pedicled Phalloplasty
Bettocchi C et al.Pedicled pubic phalloplasty in females with gender dysphoria. BJU Int. 2005 Jan;95(1):120-4.
Pedicled Phalloplasty
• Advantages
– donor sites easy to
conceal
– decreased operative
time
– +/-lower failure rate
• Disadvantages
– Less sensate overall
making insertion of a
prosthesis more risky
– Aesthetic appearance
less realistic
Free Radial Forearm Flap
• Blood supply : Radial Artery
• Innervation: medial and lateral antebrachal
cutaneous nerves
• Can be tubed for single stage urethral
reconstruction
Free Radial Forearm Flap
Free Radial Forearm Flap
Free Radial Forearm Flap
Free Radial Forearm Flap
Free Radial Forearm Flap
Free Radial Forearm Flap
Free Radial Forearm Flap
Free Radial Forearm Flap
Free Radial Forearm Flap
• Advantages
– Pliable
– relatively hairless
– erogenous sensation
– allows urethral
reconstruction in a
single stage
• Disadvantages
– donor site can be
difficult to conceal
– cannot close donor
site primarily
– rigid prosthesis is
required for
penetration
Free Radial Forearm Flap:
Outcomes

Monstrey et al have on of the largest series of radial
forearm phalloplasties with 287 patients.
• 100% of patients had tactile sensation at one year,
making insertion of a penile prosthesis safe
• 80% had erogenous sensation
• Complications with the penile implant were most
common (44% requiring removal due to infection,
erosion or leakage)
• Urologic complications were second most common
(41% overall, fistulae more common than strictures)
Free Radial Forearm Flap:
Donor Site Outcome

Selvaggi retrospectively reviewed the donor site morbidity in
129 patients who had undergone radial forearm phalloplasty
 Average flap size=228cm2, often including the Palmaris
tendon, incision extending to the antebrachial fossa.
 Complications comparable to that of small radial forearm
flaps and included partial skin graft loss, decreased
sensitivity, swelling, decreased range of motion
 No difference in patient reported aesthetic satisfaction
between full thickness and split thickness skin grafts.
Free Myocutaneous Latissimus Dorsi Flap
• Blood Supply: thoracosorsal vessels
• Innervation: thoracodorsal nerve
• 17x 15 cm cutaneous rectangle with a strip of
latissimus dorsi
• Often done in 2 stages
Free Myocutaneous Latissimus Dorsi Flap
First stage of Latissimus Phalloplasty
Free Myocutaneous Latissimus Dorsi Flap
Donor Site at 4 months
Free Myocutaneous Latissimus Dorsi Flap
• Advantages
– Concealed donor site
– Minimal donor site
morbidity
– Cuff of muscle for
urethra
– Usually less hairy
• Disadvantages
– Taken from less
sensate part of the
body
– Can be bulky and
difficult to fold
– Pedicle is short
sometimes requiring
vein grafts
Free Osteocutaneous Fibula Flap
• Blood supply: peroneal vessels
• Innervation: lateral sural cutaneous nerve
• Harvested in a single stage or prelaminated for urethral
reconstruction
• Can harvest with or without bone
• Proximal skin paddle is more sensate and forms the
dorsal side of the penis
Free Osteocutaneous Fibula Flap
Dorsql*
ventral
Free Osteocutaneous Fibula Flap
• Advantages
– Donor site easy to
conceal
– Bone can be used
instead of a prosthesis
– Prelamination of
urethra decreases
fistula rate
• Disadvantages
– Less sensate
– hairy
– Bone makes penis
constantly erect
– Bone obviates the
need for a penile
prosthesis but can
resorb warp or
fracture over time and
can be difficult to
conceal in pants
Anterolateral Thigh Flap
• Blood supply : descending branch of the lateral
femoral circumflex vessels
• Innervation: lateral femoral cutaneous nerve
• Used as a Pedicled or free flap
• Cuff of fascia or vastus lateralis mm. can be used for
the urethral reconstruction or to wrap the penile
prosthesis
Anterolateral Thigh Flap
First stage of ALT phalloplasty
Anterolateral Thigh Flap
• Advantages
– Donor site easier to
conceal
– Minimal donor site
morbidity
– Cuff of muscle for
urethra
• Disadvantages
– Less sensate than
radial forearm
– Cannot close donor
site primarily
– Donor site often
hairy
– Can be bulky
Urethral Reconstruction
• Prelamination:
– Graft tubed around a foley placed into a vascular territory
before the flap is transferred; the blood supply is not
manipulated. The flap becomes multilayered with support
and lining for a composite reconstruction
• Single stage:
– Flap is tubed at the time of harvest of the flap and
anastamosed to the native urethra
• Two Stage:
– Flap is harvested and inset but the urine is diverted;
– Urethra is created at a second stage 3 months later
Single Stage Urethroplasty
Two Stage Urethroplasty:
Graft placed at time of flap and tubed
several months later
Urethral Reconstruction:
Complications
• Urinary complications (strictures and fistulas) are very
common (as high as 80% in some series). Majority
occur at the native urethral-neo urethral anastamosis
• Prelamination or Secondary urethroplasty are
methods which attempt to reduce stricture or
Testicular implants
4 x 6 cm
• Can be done under local
• Timing up to your surgeon often done
at a second stage 3-6 months later
Penile Prosthesis
• Inserted at a second stage when the neo-phallus healed
and protective sensation returned
• Rigidity required for penetration
• Stage of phalloplasty with the highest complication rate
• Complications: erosion, exposure, infection, mechanical
failure and penile fibrosis
• Autologous tissues can resorb or fracture (bone and
cartilage)
Sensation and Sexual Function
• Dorsal penile nerve or dorsal clitoral nerve: erogenous sensation
• ilioinguinal nerve: tactile and protective sensation
• Radial forearm free flap most sensitive
(radial forearm vs ALT vs fibula)
• In transgender patients Dorsal hood of the clitoris is fixed directly below
the reconstructed phallic shaft and incorporated into the neoscrotum
• DeCuypere et al and Selvaggi et al report 100% ability to achieve
orgasm
– (Both studies: FTM RFFF coaptation of the medial and lateral antebrachial
N. to the ilioinguinal and dorsal sensory N.)
Complications
• Partial or complete flap loss
• Dribbling/incontinence
• Urethral stricture/fistula
• Infection or extrusion of penile prosthesis
• Loss of erogenous sensation
• Bleeding (vaginectomy)
Metoidioplasty
http://www.metoidioplasty.com/articles/metoidioplasty-surgical-technique.html
Metoidioplasty
http://www.metoidioplasty.com/articles/metoidioplasty-surgical-technique.html
Phalloplasty vs. Metoidioplasty
Phalloplasty
Metoidioplasty
Penile length
7 inches
1 inch
Stages
1-3
1-2 (testicular implant)
Length of surgery
8-11 hours
2-5 hours
Days in hospital
5-7
3-5
orgasm
Possible
possible
Erection
Possible
Not possible
Penetration
Possible
Not possible
Ejactulation
Not possible
Not possible
Procreation
Not possible
Not possible
Void standing
Possible
Possible
Cost
Much more expensive
Less expensive
Surgery for Affirmed Women
(Male to Female)
• Facial Femminization
• Removal of Adam’s Apple/ Tracheal Shave
• Augmentation Mammoplasty
• Genital Reconstruction:
– Orchiectomy, penectomy, vaginoplasty
Breast augmentation
Breast Augmentation
Nipples point to the side
wide inter-mammary space
****will remain like that after implant surgery
Breast Augmentation
Breast Augmentation
Breast augmentation - Complications
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Asymmetry:10%
Capsular contracture : 5-30%
Implant rupture: saline vs. silicone
Infection: 1% - start on antibiotics
immediately!
• Loss of nipple senation: 1-5%
• Hematoma: 1%
Facial Feminization Surgery
• Forehead modifications/ Scalp advancement
• Cheek/zygoma Augmentation/Fillers
• Rhinoplasty
• Mandibular Angle Reduction
• Genioplasty
Male vs Female Skull
FEMALE
four-fifths the size of its male counterpart
Overall shape Oval
Forehead: round convex smooth
Nose :more delicate
Zygomatic prominence: thinner bone more prominent
Mandible: softer angles
Chin: pointed trapezoidal
Soft tissue: more fat, softer wrinkles (i.e. Romberg masculine
Becking et al Clin Plast Surg 2007
features)
Tracheal Shave

Risks:
 Prominent scar
 change in vocal quality
(weakness, change in
pitch, raspiness,
hoarseness. The more
cartilage removed, the
greater the risk)
 pain and difficulty
swallowing
Tracheal Shave
Removal of the Adam’s Apple
Vaginoplasty
• Donor Site
– Penile/Scrotal Turn in
– Colon
– Rectus
– Groin
– Gracilis
– Thigh
Stages of Vaginoplasty
• Hair removal from penile shaft and central 2/3 of
scrotum
– ( Laser or electrolyis; Takes 3-6 months )
• Creation of an introitis/Vagina
• +/- Labioplasty or revisions
Vaginoplasty
• Uses the penile and scrotal skin to create an introitus/vagina (based
on length may need skin grafts)
• The dorsal penile nerves and the glans penis are used to create a
clitoris
• The urethra is shortened
• Testicles are removed
• 3-5 day hospital stay
• Urinary catheter and vaginal packing removed on day 5
Vaginoplasty
Dr Toby Melltzer on http://www.annelawrence.com
Labioplasty
Dr Toby Melltzer on http://www.annelawrence.com/labiaplasty.html
Post-Operative Care for Vaginoplasty

Dilation
› Increasing sizes are used to gradually widen and
maintain the vaginal opening
› during any prolonged periods of sexual inactivity,
basic dilation must be done at least once or twice a
week to insure maintenance of vaginal width and
depth
Vaginoplasty Complications
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damage to the bladder
Injury to nerves
Recto vaginal fistula
Urethral vaginal fistula
Stenosis (scarring or erectile tissue)
Sexual Dysfunction (loss, hypersensitivity)
Vaginoplasty
• Note the Prostate is not removed therefore
routine rectal exams are still required in these
patients
• The cowpers glands are left intact and thus
provides adequate lubrication for sexual
intercourse
Conclusions
• LIMITED outcomes data– We need more
• No data that demonstrates regret when properly
selected and counseled preoperatively
• Select a board certified and well trained surgeon
with experience in gender reassignment surgery
• Many options; Surgery is not without risk