Transgender surgery is performed as part of the treatment process for patients with "gender dysphoria" or "gender identity disorder". From the time they were very young, transgender patients have felt that they were born with the wrong external genitalia. They view gender-altering surgery more as "gender confirmation surgery" rather as "sex re-assignment surgery". In other words, they simply want their outward appearance to mirror the person they are inside. All transgender-related surgical procedures are performed on patients only after appropriate psychological evaluation is in place, and it has been determined that the planned procedures are in the patient's best interest and welfare. The Institute has an international reputation for for the quality and innovative surgical techniques provided to transitioning patients. Our surgical techniques have been featured on several Discovery Health Channel and Showtime medical documentaries.
Female to Male (FTM) Surgery
Female-to-male surgical procedures are performed on patients undergoing female-to-male transition. Treatment modalities fall into several categories: hormone therapy for masculinization of body and male-pattern hair distribution, "top surgery" procedures aimed at removing breast tissue, "lower surgery" procedures aimed at genital alterations, and body contouring procedures to optimize male body contour.
Patients who are heavy, and have a considerable amount of lateral chest fatty tissue, may benefit from combing the mastectomy with free nipple graft with liposuction of the lateral chest. In these patients, combining these procedures reduces the need for lateral chest revisions.
Another technique for breast tissue removal is the peri-areolar subcutaneous mastectomy, commonly referred to as the "keyhole mastectomy". This procedure has the advantage of much less scars. However, this procedure is suitable for patients who have a small amount of tissue and minimal excess skin. The ideal candidate for this procedure is a young patient who is thin and has a small amount of breast tissue.
UROGENITAL RECONSTRUCTION (BOTTOM SURGERY)
Reconstruction of the genital region is aimed at addressing a number of issues: eliminating the vaginal canal, construction of a new penis (neophallus), construction of a scrotum with testicular implants (scrotoplasty with implants), and urinary hookup. Patients may elect to address some or all of these issues. Procedures for bottom surgery tend to fall into two categories: phalloplasty procedures and metoidioplasty procedures. The Institute performs a variety of metoidioplasty-related procedures.
CENTURION PROCEDURE (ENHANCED METOIDIOPLASTY)
The "Centurion procedure" was developed at the American Institute For Plastic Surgery in an effort to enhance the existing metoidioplasty. A standard metoidioplasty creates a neophallus by performing a "clitoral release". The resulting neophallus is limited to the existing length and girth of the hormone-enlarged clitoral gland. The Centurion procedure enhances the girth of the neophallus by re-routing the round ligaments into the neophallus to add bulk to the neophallus. the round ligament are fibro-fatty structures that run down the inguinal canal and insert into the labia majora. At the time of scrotal reconstruction, these ligaments are carefully dissected free from their labial insertion and re-routed into the shaft of the neophallus, thus augmenting the girth of the neophallus.
The scrotoplasty with implants is performed at the same time as the formation of the neophallus. The testicular implants a re constructed of soft, solid, medical grade silicone.
If a vaginectomy is to be performed at the time of the Centurion procedure, a hysterectomy is required prior to the surgery. Typically, we recommend that the hysterectomy be performed at least two weeks prior to the lower surgery, although this time period may vary depending on the individual patient. We perform a mucosal vaginectomy to remove the secretion-forming vaginal wall while maintaining the muscular integrity of this region of the pelvis.
A urethral hookup is something that every patient would like to have. The ability to perform a hookup at the time of the initial surgery depends on the quality of the tissue available for the urethral lengthening. The labia minora tissue is typically used to create the neo-urethra. If a patient has adequate tissue for this, the hookup can be done simultaneously with the initial surgery. If there is inadequate tissue, then the initial reconstruction is done without the hookup. The urethral reconstruction is then done later in two stages. The first stage will involve the laying of a skin graft that will form the lining of the urethral tube, and the second stage is performed to create the tube. These stages are performed approximately six months apart.
ADDITIONAL (FTM) PROCEDURES
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Pectoral Implants: these implants are made of silicone and come in a variety of sapes nad sizes that can be tailore to the needs of the individual patient. The implants are placed beneath the pectoral muscle, either at the time of the initial top surgery or at a later date, and can give a more "fit" appearance to the male chest.
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Body contouring: this is typically done with liposuction to reduce the reduce the hip or thigh appearance and thus create a straighter, male contour to the lower body. Patients with a considerable amoubnt of abdominal skin and fat amy elct to have a tummy tuck (abdominoplasty) performed as well. It is important to realize that success with any body contouring procedure is contingent upon the patient doing his part to live a healthy, fit lifestyle.
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facial implants: while testosterone does a good job of masculinization of the face, some patients elect to have a chin or mandibular (jaw angle) implant to create a stronger, more masculine appearance to the face.
Male-to-Female (MTF) Surgery
The male-to-female transgender surgical process focuses on the areas of SRS (sex-reasignment surgery), facial feminization, breast surgery, and body contouring. The surgeons at the American Institute for Plastic Surgery have performed have been performing male-to-female feminization procedures for over fifteen years. Our exceptionally trained staff has a reputation for compassionate, quality care that provides our patients a comfortable environment for their procedures.
Facial Feminization Surgery (FFS) is a cornerstone in successful MTF transition. It is critical that key components of the facial features be addressed in FFS. Individual surgeons have different philosophies in their approach to FFS. It is important that a patient choose a surgeon whose surgical philosophies are in line with their personal goals.
Aesthetically, the face can be divided into three portions: an upper, middle, and lower third. Each of these portions consists of distinct features that must be specifically addressed in order to effectively achieve optimal feminization.
· Upper third: the upper third of the face addresses features such as male-pattern bony bossing, position of the brows, and forehead height. Our typical surgical approach involves a modified hairline incision. This approach allows full access to the bony structures of the forehead, The central bossing is reduced as is the lateral orbital rims to create a softer appearance to the forehead. The muscles between the brows are weakened as well to provide additional softness. The modified hairline incision allows for some downward advancement of the hairline, which can later be supplemented by hair grafting if needed.
· Middle third: this portion of the face includes the eyes, cheeks, and nose. Beautiful eyes are essential in the feminine face. A simple glance at countless women’s magazines showcases the importance of youthful eyes in the female face. The upper eyelid surgery (upper lid blepharoplasty) is aimed at removing excess skin and fat deposits from around the upper lid. Lower lid surgery (lower lid blepharoplasty) is aimed at reducing the appearance of bags below the eyes and tightening the lower eyelid muscles to restore a youthful appearance to the eyes. The cheek (malar) area is essential in the feminization process. The cheek male cheek is typically flatter in appearance than the female cheek. We address this by enhancing the cheek with an implant at the time of surgery. This implant is placed over the bony surface of the cheek to restore a youthful, feminine quality to the cheek. Nasal appearance is essential to address. The strong, prominent appearance of the typical male nose is addressed with a rhinoplasty. Every attempt is made to create a nose that is feminine, elegant, and age appropriate.
· Lower third: this portion of the face extends from the bottom of the nose to the bottom of the chin. This is a critical area in feminization. The distance between the bottom of the nose and the border of the upper lip is the “lip length” or labral height. The male face typically has a long upper lip with little or no visibility of the upper teeth. The youthful female face is characterized by a shorter distance between the base of the nose and the upper lip with more visibility of the teeth. We correct this problem with a technique called an endonasal lip lift. This technique was developed at our center nine years ago, and we have performed hundreds of these procedures. The other aspect of the perioral area that is essential to address is lip fullness, lip lines, and lip curl. This can be done with temporary injectable fillers or fat transfers. The problem with these techniques is that they require repeat treatments every few months that are inconvenient, painful, and costly. Our preferred method of lip enhancement is the use of the new Perma Facial Implant. This implant is made from soft, solid silicone designed to conform to the natural shape of the lip. It comes in various sizes depending on the need of an individual patient, and can easily be size adjusted if needed. The implant is permanent, yet easily reversible. Many patients, due to age or smoking, may have a considerable amount of lines and winkles around the mouth. This can be addressed with CO2 laser resurfacing. The jaw line is the final feature of the lower face that needs to be addressed. Some surgeons will specifically target the angle of the jaw to create a weaker appearance in an effort to create a more feminine jaw line. Our philosophy is somewhat different. There are many beautiful women with striking jaw lines, Christie Brinkley, Elle McPhearson, and Sophia Lauren to name but a few. A strong angle to the jaw can allow for excellent structure of the face. The aspect of the jaw that we feel is essential to address is the chin region. The male chin is typically square in appearance as apposed to the slightly more narrow, softer appearance of the female chin. We address this feature by re-contouring and reducing the square-ness of the chin to a more feminine appearance.
· Brow lift with bony re-contouring and hairline advancement
· Upper and lower eyelid surgery (blepharoplasty)
· Cheek enhancement with implant ofr fillers
· Nasal re-shaping (rhinoplasty)
· Perioral feminization with endonasal lip lift and lip enhancement with Perma facial Implant
· Face/neck lift
· Bony softening of the chin region
· CO2 laser skin re-surfacing
· Tracheal shave
BREAST AUGMENTATION IN THE MALE-TO-FEMALE (MTF) PATIENT
Breast augmentation in the MTF patient requires an understanding, on the part of the surgeon, of the differences in pectoral muscle characteristics between female and male anatomy. This understanding is what enables results that are feminine in appearance and satisfying to the patient. Breast augmentation can be performed with either saline or silicone gel implants. Since the FDA released gel implants for general use in 2007, the majority of our patients have chosen gel-filled implant as apposed to saline filled implants.
The implants are typically placed under the pectoral muscle. We feel that a sub-muscular placement provides a more natural result with less implant visibility.
The selection of incision is made in collaboration with the patient. WE typically prefer the incision to be placed in the fold of the breast. This allows for better management of the pectoral muscle and more precise placement of the implant. The peri-areolar incision is typically not the preferred incision due to the fact that most MTF patients have a small, often light colored areola that can leave a more visible scar.
LIPOSUCTION AND BODY CONTOURING IN THE MALE-TO-FEMALE (MTF) PATIENT
Body shaping procedures in the MTF patient are aimed at optimizing the female shape. This typically involves performing liposuction throughout areas of the mid-body such as the abdomen, midriff, flanks (love handles), and mid-back. By reducing these areas, we are able to enhance the hourglass appearance that is optimal in a woman. Some patients will elect to have some of the suctioned fat to be transferred to the outer thigh/buttocks area to further enhance their shape. The principle downside to fat injections is the inherent uncertainty as to how much of the fat will persist over time.
ORCHIECTOMY
MTF patients typically start female hormones prior to sex re-assignment surgery (SRS). In conjunction with hormone replacement therapy, MTF patients typically take testosterone-blocking medications such as aldactone to block testosterone that is produced by the testes. Certain patients may choose to delay their SRS for a number of reasons. Some of these patients may elect to undergo an orchiectomy (surgical removal of testes) as an interim procedure. This procedure eliminates the need for testosterone blockers. It is crucial that the decision to undergo an orchiectomy be a well thought out process due to the irreversible nature of this procedure. The decision for a patient to undergo and orchiectomy is done in conjunction with support from their therapist.
The orchiectomy procedure is performed through two small incisions in the groin region without placing an incision on the actual scrotum. This ensures that the scrotal skin integrity is not compromised in any way for future SRS.
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