MTF GRS
Overview
Dr. Meltzer performs a two stage vaginoplassty/labiaplasty Male-to-Female Gender reassignment procedures in adherence with the WPATH Association previously known as the HBIGDA standards of care Harry Benjamin International Gender Dysphoria Association . There are many additional procedures that Dr. Meltzer can do to give your face and body a more feminine appearance. He does both soft tissue and bone work.
Core GRS procedures
Feminizing procedures
- Mammoplasty/Breast augmentation
- Tracheal shave
- Facial Feminization
- Face Lift
- Reduction of the Mandibular Angle
- Genioplasty - Reduction or Re-shaping of the chin
- Cheek Implants
- Brow Reduction
- Brow Contour
- Scalp Advancement
- Brow Lift
- Blepharoplasty ("eyelid surgery")
- Lip Lift
- Lip Augmentation
- Body Sculpting
- Liposuction
- Abdominoplasty
- Buttock Augmentation
- Information
- Links to physicians who perform other procedures:
- Voice surgery, also known as Cricothyroid Approximation, performed by Dr. James Thomas
- Hair Loss
- Other Questions
Vaginoplasty
The surgery for male-to-female gender reassignment is done by Dr. Meltzer. For unusual or complicated cases, he may involve a urologist.
Penile inversion technique for vaginoplasty
- This surgery is done under general or spinal anesthesia.
- The testicles and the erectile tissue of the penis are removed.
- A vaginal space is created below the urethra (urinary tube).
- The penile skin is used to line the vaginal vault, which eliminates the need for skin grafts in most cases. In patients with a shorter penis (less than 5 inches 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, Dr. Meltzer can create a sensate clitoris. A small portion of scrotum is used to fashion the labia (the lips of the vagina).
- A cotton stent is placed in the vagina. The stent stays in place for five to six days.
Risks
This procedure is not without risks. For the vast majority, the surgery is safe and the recovery uneventful. The rate of satisfaction is very high, but complications can occur and the informed patient must be aware of them.
- Bleeding is a risk of any operation, particularly those procedures involving the pelvis, although the need for a transfusion is exceedingly rare. If you are particularly concerned about transfusion of blood products, then it would be 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 at our office.
- An abnormal path between the rectum and vagina is called a rectovaginal fistula. Should this occur, it is possible that one would have both gas and feces come through the vagina. In order to reliably close this communication a temporary colostomy might be required. A secondary operation can close the colostomy three months later. In my own practice, this has been a very rare complication though it is more concerning due to its implications.
- An abnormal communication between the urethra and vagina is also possible, however, this is 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 gynecologic 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. Special padding and careful positioning of the legs are used in surgery to minimize the risks.
It is very important for a prospective patient to inform Dr. Meltzer of any unusual situations or conditions that may have impact on the procedures.
Referral letters and payment
Dr. Meltzer adheres to the WPATH Harry Benjamin International Standards of Care. The SOC requires two referral letters from appropriately credentialed individuals before the patient can have their surgery.
All patients are required to submit a $750.00 non-refundable deposit to schedule any surgery. If you need to cancel or reschedule your surgery date, your will need to give at least eight weeks' notice. Your deposit will reserve your surgery date. Every attempt will be made to honor your date, but circumstances beyond Dr. Meltzer's control may necessitate a date change.
50% of fees are due six weeks prior to surgery and the remaining 50% is due four weeks prior to your surgery. You can pay for your surgery by cashier's check, money order, Visa or MasterCard. Some patients find it convenient to have their bank wire the funds.
Preoperative instructions
Once surgery is scheduled, a patient will receive a letter confirming both the date for the preoperative appointment and the surgery.
- A patient must stop hormones two weeks prior to surgery.
- Referral letters from the patient's therapists must be sent directly to our office at least three months before their surgery date.
- Please contact our patient care coordinator, Carole Barkley, or our practice manager, Linda Takata, via e-mail or by phone at 866-876-6329 or 480-657-7006 to schedule a consultation visit or surgery date with Dr. Meltzer.
- Medications: Unless otherwise directed by your physician, do not take any Aspirin, Vitamin-E, or non-steroidal anti-inflammatory (i.e.: Advil, Aleve, Ibuprofen) three weeks prior to your surgery, since this interferes with normal blood clotting. If you need a pain medication for general purposes, use Tylenol or if you are in doubt about any medications you are taking, please contact our office. Please see the attached list for products that contain Aspirin, Ibuprofen, or Vitamin E.
- If you are taking any medications on a regular basis, please let Dr. Meltzer know, especially if you are taking any cardiac or hypertensive medications (such as Beta-Blockers). If your are on several medications, please bring a list with dosage and type to the hospital with you.
- Take your regular medications as you normally would with a small sip of water, the day of surgery, unless otherwise instructed.
- Smoking significantly increases the risk of complications during and after surgery. It is in your best interest to stop smoking as soon as possible. You are required to stop smokng no less than one month before surgery. You will need to sign our form stating that you understand this requirement and agree to stop smoking.
- Please report any signs of a cold, infection or skin lesion anytime prior to your surgery.
- You may not have anything to eat or drink after midnight before your procedure. Please check with your physician. (Please notify your physician if you are diabetic or have any other concerns regarding this instruction.)
- On the day of your discharge, please be prepared to have someone drive you or to take a cab. If you have had any prescription pain medication, you cannot drive. In addition, please make sure you will have someone at home to assist you.
Products containing aspirin
| Alka-Seltzer | Cope | Fiogesic | P-A-C |
| Anacin | Coricidin | Fiorgen | Percodan |
| Anexsia with Codeine | Damason | Fioricet | Presalin |
| Andynos | Darvon | Fiorinal | Robaxasil |
| Aspirin | Dristan | 4-Way Cold Tablet | Roxiprin |
| Aspirin suppositories | Dia-Gesic | Gemnisyn | Saleto |
| Ascriptin | Digel | Indocin | Salocol |
| Aspergum | Dolprin #3 tablets | Liquiprin | SK-65 Compound |
| Axotal | Donatab | Lortab | Sine-Aid |
| B-A-C | Doxaphene | Magnaprin | Sine-Off |
| Baby Aspirin | Duragesic | Marnal | St. Joseph |
| Bayer | Easprin | Meprobamate | Supac |
| BC Powder | Ecotrin | Midol | Talwin Compound |
| Bexophene | Emagrin Forte | Momentum | Trigesic |
| Buffaprin | Empirin | Norgesic | Tolectin |
| Bufferin | Emprazil | Norwich | Triaminicin |
| Buffinol | Equagesic | Orphengesic | Vanquish |
| Cama-Arthritis Strength | Equazine | Oxycodone | Zorprin |
| Congespirin | Excedrin | Pabalate | Zomax |
Products containing Ibuprofen
| Advil | Medipren | Midol 200 | Nuprin |
| Haltran | Midol | Motrin | Rufen |
Other products which promote bleeding
| Vitamin E | Marine Fatty Acids | Omega-3 Fish Oil Supplements |
A note on products that interfere with blood clotting
It is necessary to discontinue the use of any of these products as they may inhibit the normal blood coagulation mechanism and may cause excessive bleeding and bruising during or after the surgery.
If you are in doubt as to whether or not the medication you are taking will interfere with your surgery, please call your physician.
A note on smoking
Smoking can significantly affect the outcome of your procedure. Please be aware that the long term effects of smoking cause a narrowing of the small arterial blood vessels that traverse the skin. This decreases the circulation of the tissues of the skin and makes it necessary for the surgeon to be more conservative in any plastic surgery procedure. Smoking near the time of surgery causes a further acute narrowing of the blood vessels which may cause ischemia of the tissue, poor healing, bad scars, or actual loss of tissue.
Questions
Please contact our office at 866-876-6329 or e-mail Carole Barkley or Linda Takata for current pricing and questions about scheduling.
Hospitalization
Following surgery the patient will stay in a private suite in the hospital for nine nights. At this time patients may be discharged, either to return home or to stay in one of the many hotels somewhere in the Scottsdale area if they wish to remain longer.
Post-Operative Care and Procedures
- Dilation: The cotton stent is removed from the vagina and it is then necessary to start gently dilating the vagina four times a day for the first month following the dilation instructions provided by Dr. Meltzer. One needs to gently dilate the vagina after surgery, otherwise, it will narrow and collapse. The need to dilate becomes 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.
- Urinary catheter: The catheter will be left in place for 8 days. After the catheter is removed, one will be able to urinate while sitting.
- Labiaplasty: Dr. Meltzer can usually create a very normal appearing vagina in one stage. However,a secondary labiaplasty is recommended, though not required, at least 3 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. You can find more information on Dr. Meltzer's labiaplasty procedure here.
Fees
Please contact our office at 866-876-6329 or 480-657-7006 or e-mail Carole Barkley for current pricing and/or scheduling.
Insurance Policy
Dr. Meltzer does not participate with any insurance plans. The patient will need to pay the fees in advance and submit their own claim. Dr. Meltzer will provide you with an itemized statement to submit to your insurance company.
Other Procedures
Dr. Meltzer performs a full spectrum of feminizing procedures such as tracheal shave, voice surgery and brow contouring; as well as, aesthetic procedures of the nose, face, eyelids and chin, along with liposuction and body sculpting. The fees are dependent upon the procedure itself and can be provided upon request. It is possible to have aesthetic procedures performed at the same time as sex reassignment. Please check with both Dr. Meltzer and Carole Barkley regarding time constraints and allowable combinations of procedures.
Labiaplasty
A labiaplasty may be done as soon as three months following the vaginoplasty. This operation is not required and some patients may not find it necessary. The purpose of a labiaplasty is to better define the inner labia and to provide hooding and coverage to the clitoris. During this procedure, Dr. Meltzer can also revise the urethral opening or make functional improvements to the vagina if necessary.
- The incisions are located at the edge of the inner labia and in the midline of the mons in the pubic area. The labial incisions heal almost imperceptibly. The mons incision heals very nicely and is hidden by the pubic hair. Initially there is usually some swelling which will resolve over the next month.
- A labiaplasty is an outpatient procedure done under local anesthesia. Patients are required to stay on strict bed-rest until the next morning.
- Out of town patients are required to stay a minimum of one night in the hospital. If you have a long trip home (flying or driving), it is recommended that you stay two nights. One of these nights can be in a hotel.
- All sutures are self-dissolving, though some will take weeks to fall out.
- You must keep an ice pack on the area continuously for the first 12 hours and then intermittently for the next 36 hours.
- You should plan to take a couple of days off work to recuperate and not plan on doing any heavy lifting for approximately one week after surgery.
- You will want to check with Dr. Meltzer or one of the nurses for instructions on when you may resume dilation. It will depend on how much work (if any) Dr. Meltzer needed to do with the urethra. Some patients can resume dilation in as early as 2-3 days, while others will be asked to wait 5-7 days.
- This procedure is fairly low risk from the surgical standpoint. The principle associated risks are that of any operation, which would be bleeding or infection.
Please contact our office at 866-876-6329 or 480-657-7006 or e-mail Carole Barkley or Linda Takata for current pricing and questions regarding scheduling.
Mammoplasty: Breast Augmentation for MTF
Dr. Meltzer's goal in breast augmentation is to enhance the breast volume and shape as much as possible and to maintain a very natural look. Most patients will see a majority of their breast growth with their hormonal therapy. Although some patients will get even larger following GRS, most patients see a modest increase from GRS alone. There is no contraindication to having breast augmentation prior to or during GRS and it will have no adverse effect on future breast development.
Technique
The procedure is usually done under general anesthesia. The implant can either be placed through an incision following the lower edge of the areola (the pigmented portion of the nipple) or through an incision in the crease of the breast. Dr. Meltzer's preference is the areolar incision, since in a majority of cases the scar is almost imperceptible. Furthermore, if the scar is apparent, it can be easily tattooed to match the areola. There is no greater risk of nipple numbness using the areolar incision than other incisions. The reported risk of nipple numbness in breast augmentation is approximately 20%; however, Dr. Meltzers experience is that it is much less. The incision in the crease of the breast heals also quite nicely; however, it takes considerably longer to fade and may be noticeable if one lifts up the breast or views it from below. The implant can be placed either below the breast tissue or below the muscle. In most patients, Dr. Meltzer prefers to place the implant below the muscle, to prevent feeling or seeing the implant. Initially, the breasts are somewhat firmer from swelling, but this will soften over the next four to six weeks. Following breast augmentation, it is advisable to move the breast over the implant, once daily, to keep this space large and the implant moveable.
The saline implants are filled with saltwater, but have a solid silicone outer core. The FDA has not raised concerns about the solid silicone, only the silicone gel.
Implications on cancer breast screening
Since you have breast tissue you are at higher risk than the average male population to develop cancer of the breast. Therefore, routine breast exams and screening are important. The implant will obscure a small portion of the breast tissue during routine mammography (in some series this is as high as 20 percent). If the technician is properly informed, they can modify their technique to significantly improve the visualization.
Complications
The most common complication of breast augmentation is formation of a dense scar around the implant (capsular contracture). This is the body's response to a foreign object, and occurs in all implants to various degrees. In most cases, this capsular tightness is not severe and requires no secondary revision. However, in unusual cases it can be quite severe, causing distortion of the breast itself. Severe capsular contracture in saline implants is much less common than with silicone breast implants, and experience has shown the breasts have stayed quite soft.
Bleeding is a risk of any operation; however, should bleeding occur after the surgery and a hematoma forms, we would need to return you to the operating room to remove the blood. Fortunately, this is unusual. Implants are susceptible to infection, and should an implant become infected, it would need to be removed for several months. Dr. Meltzer has never had this complication, however, it is a risk that should be discussed. It is not meant to frighten or discourage you, but it is necessary to make sure that you are aware of the risks and complications of such a procedure.
Tracheal Shave
A tracheal shave is a straightforward procedure in which the cartilage is contoured to a flatter level.
Technique
The technique that Dr. Meltzer uses requires an incision in the area of the most prominent portion of the tracheal cartilage. This usually can be located in an existing skin crease. The incisions heal quite well; however, they can be red and noticeable for several months following surgery while they are in the healing phase.
The incision is usually 3 to 4 cm in length, depending on the size of the patient. Through this incision Dr. Meltzer is able to separate the muscles in the midline and expose the tracheal cartilage. The tracheal cartilage is reduced, usually by carving it with a knife; however, occasionally with patients with calcified tracheal cartilages, a bone cutting instrument is required. It is important to reduce the cartilage only enough to reduce the prominence and not over-resect this cartilage.Taking this too deeply is undesireable as the voice box and vocal cords are directly below these tracheal cartilages. Should this occur, it is possible that you may have some changes in your voice. Fortunately, this is fairly unusual when performing it with the technique that is used. A patient may note some breathiness or hoarseness in the first few days following surgery, but this has not been a significant postoperative or long-term problem.
The procedure is done under local anesthetic on most patients.
Sutures
The sutures used are usually one "pull-out" suture, which the patient can actually remove themselves a week after surgery.
Cost
Contact Carole Barkley for current pricing and questions about scheduling. Additional fees incurred may include but are not limited to the following: Transportation, medications, meals, lodging, ancillary services and return to the operating room.
Voice Surgery
Dr. Meltzer and Dr. James Cohen have worked together for many years performing the cricothyroid approximation procedure for patients seeking to feminize their voice. Both Dr. Meltzer and our patients have benefited greatly from Dr. Cohen's expertise and dedication to the community.
However, recent input from patients has indicated that the large University setting, where pre and post-operative care is delivered, does not always offer the individualized and personalized service patients have come to know from our office. This is a factor that is beyond Dr. Cohen's control and prompted us to seek the services of a physician in private practice. This is also one of the same reasons we chose to move our practice from Oregon Health Sciences University to a private practice setting. We want to take this opportunity to thank Dr. Cohen and his staff for all they have done. I know all of us will miss working with Dr. Cohen. Dr. Cohen and his staff will continue to work on long-term follow-up and an article due soon for publication. In addition, Dr. Cohen will still be available for questions, concerns or follow-up to patients that had there original procedure done by Dr. Cohen. This was not a decision that was taken lightly and we feel confident that the physician that will now be performing the voice procedures is strongly committed to the best possible patient care and the community.
Therefore, we would like to announce, effective February 2001, Dr. James Thomas will be performing voice surgery procedures. Dr. Thomas is an Otolaryngologist who has dedicated his entire practice to laryngology and voice disorders. His web site has a wealth of information regarding the procedure, voice disorders and his practice. For those of you that would like to know more about his educational background, this information is also provided on his web site at this direct link.
Voice surgery is not for everyone. Some patients are better candidates for voice training or a combination of the two. All prospective patients will need to meet with Dr. Thomas to determine whether they are appropriate surgical candidates. If it is determined that you are not an appropriate candidate for surgery, alternatives can be discussed at this visit.
Coordination of office visits and surgery scheduling will still be handled through our office. Please feel free to contact us should you have any additional questions. You can email Carole Barkley or call our office at 1-866-876-6329.
Hair Loss
For current patients who Dr. Meltzer has already seen, Propecia may be an option for treating excessive hair loss. Propecia has been shown in studies to reduce hair loss and may also result in some regrowth of hair in the vertex (at top of head) and in the anterior mid-scalp area. Presently studies do not support regrowth in the temporal areas. Furthermore, if you discontinue use of Propecia within the first 12 months, you will likely lose any hair you have gained.
What are the side effects?
Less than 2% of patients in clinical studies had certain side effects. These included: less desire for sex, difficulty in achieving erections and decrease in amount of semen. These side effects were reversible and went away once the drug was discontinued. For those that continued taking Propecia, 58% of the 2% stopped experiencing these side effects.
How do I know if Propecia is right for me?
Contact our office and talk with our nurse, Tasha. She can be reached at 1-866-876-6329 or 480-657-7006. She will consult with Dr. Meltzer after reviewing your health history.
How do I get Propecia?
Once you have received clearance from Dr. Meltzer, Propecia can be purchased directly through our office and sent to your home.
Questions
If you have additional questions not answered by these pages, please send an email to Linda Takata or call the office or business hours. We are open Monday-Thursday, 9:00 AM-5:00 PM.
Last modified: December 30, 2003 06:27 PM
Maintained by Linda Takata.
Disclaimer: Any external informational Web sites which may be reached from this Web site are neither maintained nor endorsed by Dr. Toby R. Meltzer or his staff, and their contents may be questionable or offensive to some.
All information © Toby R. Meltzer, MD PC, 1996-2004. Photographs provided are anonymous and also © Toby R. Meltzer, MD PC, 1996-2004.
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