Lower surgery primer

Photo by Lesly Juarez on Unsplash
[Photo of a piece of paper by a window with mindfulness written in cursive by Lesly Juarez on Unsplash[

Things to keep in mind:

  • There is no best option that best suits everyone.
  • All procedures & surgical teams have pros & shortcomings.
  • Do your own homework with a critical mind
  • Decide your priorities, factor your unique medical history, make choices accordingly.
  • Consider:
    Amount of risk you’re willing to take for different things (e.g. sensation, standing to pee, penetration, visibility of bulge, comfort/safety in public showers)
    Number of surgeries your physical & mental health can handle
    Total financial cost (e.g. time off work, out of town accommodations, travel)
    For phallo: skin donor site (considering tattoos, existing scars, visibility of scarring, permanent hair removal ahead of urethraplasty, etc)
  • Few guys have more than 1 procedure, most comparisons are approximations.

Sources of information

Some are free, some require more patience than others and all have their limitations.
Photo by Erica Nilsson on Unsplash
Photo of a sign by a body of water that says Danger thin ice keep off by Erica Nilsson on Unsplash

Please remember not all post-op guys will want to discuss their surgeries for any number of reasons. Check in if it’s a topic about which they’re in a place to answer questions and willing to do to it.

When choosing a location consider:

  • Documentation required depending on your citizenship/status
  • How much are you willing or can afford to travel? What if there’s a major complication requiring multiple trips back?
  • How will you manage being away from your local support network? If your favourite/healing food is not available?
  • What is your comfort level with language & cultural barriers? If you can only have limited communication with professionals within a foreign system? Etc.
    This depends on known languages, travel experience and so on.

Useful preparation (as it applies & is possible):

  • Make a post-op “kit” for the days following your hospital release:
    – Laxatives and whatever helps you get your bowels moving again. GA & antibiotics wreck guts, you don’t want to strain when recovering from groin surgery
    – Antihistamine and Benadryl (in case you react to post-op meds)
    – Gauze (your surgeon should provide some but maybe not enough)
    – Vinyl or latex gloves (they’re cheap at home reno centres)
    – Neck rest or breast feeding pillow to sit on while keeping pressure off sutures
    – Vaseline & extra soft toilet paper (if you must do a cleanse)
    – Compression stockings (if flying within 48 hours of your op)
    – Antiseptic cream (esp if you have sensitive skin)
    – Button down shirts (esp for MLD, RFF, combo techniques)
    – Compression sleeve (if having RFF)
    – Make a recovery playlist, save some books, shows, films, etc
    – An extra long power wire for your laptop/tablet and/or smartphone
    – Adapter if traveling to somewhere with different electrical voltage
    – Baggy pants and/or long jackets (if getting phallo, esp erectile implant)
    – Slip on shoes/flip flops & a bathrobe
    – Big plastic bags and waterproof tape to shower (if RFF or combo)
  • If your health permits, focus on working out your core muscles (e.g. abs, lower back, gluteals) to help get in & out of bed while a limb or two or three are compromised
  • Letters from GP/family physician & mental health provider(s)
  • Discuss your surgical plans with a trans+ local nurse
  • Discuss your surgical plans with a trans+ local urologist
  • Discuss your surgical plans with a trans+ local plastic surgeon
  • Donor site massaging (to stretch skin for MLD)
  • Permanent hair removal (esp if using skin for urethral lengthening)
    For an area to be deemed truly free of hair it should go through 2 full hair cycles (approx 6 months) without any regrowth. Some surgeons will claim they can remove hair at the time of surgery via cauterisation, but that can only reach about 60% of the hair, or the hair in the active growth part of their cycle. Insufficient hair removal is associated with serious urethral complications. Hair removal on the outside of the penis can be done post-surgically.
    Finding someone willing to do permanent hair removal on a guy can be tricky, especially if you’re asking to have it done on your dick/post-surgery. Ask post-op guys in your area.

None of the local professionals need to have undergone trans/Gender Affirming Surgery specific clinical training. Rather they should be willing to monitor your healing, write antibiotic/painkiller prescriptions as needed and provide assessments to the surgeon in case of serious complications. The idea is to hope for the best but prepare for the worse.

Don’t make commitments for at least the 1st two weeks following major surgeries, longer if you’re slower to heal. If travelling with someone be extra clear they can go visit sites, socialise, whatever but you should not be assumed to come along. This isn’t a vacation for you. You’ll need lots of rest, have low energy for a while and you might be dealing with medication brain fog, low energy, post-operative depression, allergic reactions to post-op medications, diaper rash, complications (see section below), etc.
Click here for a funnier piece on the recovery process.
Click here to read more a more serious piece on the physical recovery process following phalloplasty.

Consultation Questions:

  • Expected recovery time
  • What do they define as a complication, what they are, their rate of occurrence, their approach to resolving them
  • What’s the best way to communicate with them both prior and following surgery.
  • Suggested recovery underwear/position
  • Willingness to work with your local doctors in case of later complications

piron guillaume unsplash surgery[Picture by Piron Guillaume on Unsplash. Description: a surgical team around a patient, and a table with surgical instruments nearby.]

Procedures:

Scrotoplasty, Colpectomy/colpocleisis, Glansoplasty, Tattooing (of glans or whole flap), Stiffener
Release, Metoidoiplasty (aka meta), Centurion,
Urethral lenghtening (aka u hook-up or UL), nerve lengthening (aka nerve hook-up),
Phalloplasties: Ab-flap, Pubic flap, Thigh flap (inner thigh), Radial forearm (RFF), Musculocutaneous Dorsal flap (MLD), thoracodorsal (TD), Reinverted Latissmus Dorsi (RLD), Digit forearm combo (thigh or dorsal flap), Shin, Radial forearm thigh combo, Anterior Lateral Thigh flap (ALT, front part of thigh). There may be others as well.

Scrotoplasty:

Implants come in many sizes but guys are limited by the amount of skin they have. They can expand it via tissue expanders. This adds time and cost to the procedure and is not offered by most surgeons.

Colpectomy/Colpocleisis:

Some surgeons require it, others let guys decide. Some will not do it. If it is not done, the surgeon will not close the frontal hole to make future access to it possible if medically necessary. The technique has improved, most surgeons no longer require a blood transfusion. Colpectomy is removal of the organ, it is not often done anymore. Colpocleisis is cauterising the top surface so it fuses together, this is what’s typically done. Externally, you cannot tell the difference. Internally, it preserves the g-spot.

Glansoplasty:

It can be done at the same time as phalloplasty or separately. It is not uncommon for the glans to flatten over time, especially for those prone to keloid scarring. The “flattening” occurs from the crevice created behind the glans “filling up” with scar tissue as it heals. The body treats glansoplasty as a wound to heal and seeks to return the phalloplasty to its pre-glansoplasty shape. It is not offered by all surgeons.

Tattooing:

Done by some guys to address the monochromatic appearance of phalloplasty dicks. It can also help give the illusion of greater definition of where the glans ends for those who scar more. A few things to know about the process:
a. it should be done prior to getting a penile implant (if you’re getting one at all)
b. it may take a few sessions to go over the same things because the scar tissue inherent in something surgically constructed can cause the skin to reject the ink
c. some tattoo artists will want a note from a medical provider that this is safe to do
d. get it done sooner rather than later, so you feel it as little as possible

Urethral lengthening:

Tissue may come from the frontal hole (this is rare because of tissue atrophy due to testosterone), front third of the inside cheek (seldom used to do the full lenghtening for a phallo, usually more for meta or repairs in phallo), upper bowel, the inner part of a forearm, or anywhere else with relatively thin skin (since it must be rolled up and fit within the roll that makes up a phalloplasty.) If it is skin, the area must be hairless before surgery. It can be extended to the tip of your dick (whether you get meta or phallo) or the top of the scrotum. Urethral lengthening changes our risk of STI/HIV transmission. It is not uncommon to dribble post-voiding following urethral lengthening. Pushing up behind or in front of the scrotum typically resolves this problem.

Release, Meta & Centurion:

  • Lower risk of complication and loss of sensation.
  • Least visible scarring.
  • Safe pumping done prior to surgery can result in significant growth. It’s possible to cause damage to the skin and blood supply of the genitals if it is done too much or too fast.
  • Erections remain as before, don’t require surgical maintenance or precaution.

Phalloplasty:

A free flap is one formed and fully released from the donor site in one surgery. Pedicle flap is one formed but released from the donor site in multiple stages. There are differing schools of thoughts on the pros and cons of either technique between number of trips to the OR, which increase/decrease the risk of necrosis at the tip of the flap, so on.

Nerve hook up depends on availability of nerves at the donor site and/or surgeon experience with microsurgery. If none is done the flap will develop some tactile sensation from the nerves underneath the donor skin over time. Some surgeons will prioritise doing nerve hook to provide protective, hot/cold sensation over erotic, ask at your consultation!

Stiffeners:

Bone – Erect density is constant.
Semi-malleable rods – Semi-erect density is constant. Has higher rate of protrusion and displacement from anchor to pubic bone. If no issue, typically lasts approximately 5 years longer than inflatable rods. (read up studies on specific implants for greater accuracy)
Inflatable rods – Different densities. Fewer protrusion and displacement from anchor at pubic bone than semi-malleable rods. If no issue, typically lasts around a decade.
External devices: Cheap & surgery free. Some guys report paint at the base from the skin overstretching as there’s nothing anchoring the penis. Can compromise the dick’s blood flow if too tight and protective sensation is not established well enough.

alex-iby-struggle-unsplash

Complications:

Fistula – any opening besides the one at the tip of the dick that goes from the neo-urethra to the outside of body. Most will heal on their own, other will require surgical intervention.
Stricture – narrowing of the urethra to the point that someone is unable to void or not able to do it well enough. Dilation may be required for a while or until surgery can be performed to correct this. Caused by scar tissue and/or hair regrowth inside the urethra.

Necrosis – Death of tissue due to insufficient blood supply. Typically occurs at the tip of the flap. It can lead to infection and total loss of flap. It can also occur over parts of skin grafts used to cover donor sites.
Staph infections – Staphylococcus aureus bacteria can be treated in most cases with antibiotics but can lead to loss of flap. Most common to get at the time of penile implant.

Bladder Spasms – common the longer a Foley catheter is in. Do not endure them, get anti-spasm medication, and drink lots of water. It’s your body trying to expel the catheter, and if it succeeds, it can wreck your urethra and/or have to be reinserted while you’re awake.

Allergic reactions – you’ll be put on a number of medications following surgery, probably many for the 1st time in your life. You’ll be on antibiotics, painkillers, possibly anti-inflammatory and others. If you’ve never been on a medication before, you can’t know if you’re allergic to it in advance. Look out for signs such as rashes and nausea.

Post-Operative Depression – there are several reasons you might experience it. It won’t be mentioned by your surgeon because it’s not something they address. It can compromise your adherence to post-op care instructions, and that can lead to physiological complications. Regardless, know you are not alone, and find support to nurture your resilience.

marcel scholte unsplash operating room
[Picture by Marcel Scholte on Unsplash. Description: an empty operating room.]

General Aftercare:

  • A diet and supplements that promote regular bowel movements
  • Keep your pain managed
  • Keep all areas very clean
  • Watch carefully for signs of infection, necrosis, fistula, strictures and allergic reactions. The flap is insensate at first so there will be fewer clues than usual but besides visual ones monitor your body temperature and energy level.
  • Keep your dick and donor site away from cold and excessive heat to prevent compromised blood circulation and burns
  • Follow post-operative care instructions as best as you can

One thought on “Lower surgery primer

  1. Pingback: Physical recovery process from phalloplasty | Life Post-Dysphoria

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