Fundamentals of Gender Fundamentals of Gender ReassignmentReassignment

William M. Kuzon, Jr., MD, PhDWilliam M. Kuzon, Jr., MD, PhDReed O. Dingman Professor of SurgeryReed O. Dingman Professor of Surgery

Section Head, Plastic SurgerySection Head, Plastic SurgeryUniversity of MichiganUniversity of Michigan

Gender Identity DisorderGender Identity Disorder(DSM(DSM--IV 302.85)IV 302.85)

IncidenceIncidence–– Not certain but Not certain but

estimate:estimate:–– 1:12,000 males 1:12,000 males ––

25,000 in US25,000 in US–– 1:30,000 females 1:30,000 females ––

10,000 in US10,000 in US

EtiologyEtiology–– BiologicalBiological–– Social LearningSocial Learning–– Cognitive Cognitive

DevelopmentDevelopment

“A strong and persistent identification with the opposite gender.”

History of Treatment of GIDHistory of Treatment of GIDDr. Harry Benjamin Dr. Harry Benjamin -- endocrinologistendocrinologistHBIGDA HBIGDA –– www.hbigda.orgwww.hbigda.orgNow WPATH Now WPATH –– World Professional Association for World Professional Association for Trangender Health Trangender Health –– www.wpath.orgwww.wpath.org““Standards of CareStandards of Care””John Hopkins Program 1970John Hopkins Program 1970’’ssFree University of AmsterdamFree University of AmsterdamResurgence of sex reassignment surgery in North Resurgence of sex reassignment surgery in North America America –– accelerating public awarenessaccelerating public awarenessMajor Centers in Europe, North America, AsiaMajor Centers in Europe, North America, Asia

UM CGSPUM CGSPProgram coordinator tracks Program coordinator tracks all patientsall patientsEMPHASIS ON EMPHASIS ON MULTIDICIPLINARY CAREMULTIDICIPLINARY CARE–– TherapistTherapist–– Primary carePrimary care–– Specialty careSpecialty care–– Second opinionSecond opinion–– Surgical ReferralsSurgical Referrals

Plastic SurgeonPlastic SurgeonUrologistUrologistGynecologistGynecologist

–– Other providers (electrolysis, Other providers (electrolysis, speech therapy)speech therapy)

Mental Health TeamMental Health Team–– Readiness for surgeryReadiness for surgery

Core TeamCore Team–– Surgical TransitionSurgical Transition

WPATH Standards of CareWPATH Standards of CareDesigned to protect Designed to protect both patient and both patient and providerproviderA A ““roadmaproadmap”” for sex for sex reassignmentreassignment–– PsychotherapyPsychotherapy–– Hormonal TherapyHormonal Therapy–– Real Life TestReal Life Test–– Verification of readiness Verification of readiness

for SRS by mental for SRS by mental health professionalshealth professionals

MaleMale--toto--Female (MTF)Female (MTF)

? Majority of GID patients? Majority of GID patientsRange of Surgical OptionsRange of Surgical Options–– Facial FeminizationFacial Feminization–– Thyroid Cartilage ReductionThyroid Cartilage Reduction–– Breast AugmentationBreast Augmentation–– SRSSRS

MaleMale--toto--Female (MTF)Female (MTF)

Facial FeminizationFacial Feminization–– Hairline correction Hairline correction –– Forehead Forehead

recontouring recontouring –– Brow lift Brow lift –– Rhinoplasty Rhinoplasty –– Cheek implants Cheek implants –– Lip lift Lip lift –– Lip filling Lip filling –– Chin recontouring Chin recontouring –– Jaw recontouring Jaw recontouring

Facial FeminizationFacial Feminization

Thyroid Cartilage ReductionThyroid Cartilage Reduction

MTF MTF –– Breast SurgeryBreast Surgery““TopTop”” surgerysurgery

Sub-muscular augmentation350 ml saline implant

MTF SRS (MTF SRS (““BottomBottom”” surgery)surgery)Penile Inversion VaginoplastyPenile Inversion Vaginoplasty

One stage operationOne stage operation““LikeLike”” becomes becomes ““LikeLike””Reliable and predictableReliable and predictableGood functional and aesthetic resultsGood functional and aesthetic resultsAcceptable complication rateAcceptable complication rate–– Tissue lossTissue loss–– Rectal fistuaRectal fistua

MTF MTF –– Penile Inversion VaginoplastyPenile Inversion Vaginoplasty

D/C hormones 3 weeks pre opD/C hormones 3 weeks pre opMechanical Bowel Prep day priorMechanical Bowel Prep day priorOR OR –– 44--6 hours6 hours–– Possible need for transfusionPossible need for transfusion–– CatheterCatheter–– Vaginal packingVaginal packing–– DrainsDrains

Removal of pack, catheter, and drains POD 4Removal of pack, catheter, and drains POD 4Vaginal Rinses x 3 weeksVaginal Rinses x 3 weeksRestart hormone therapy when return to OR is r/oRestart hormone therapy when return to OR is r/oVaginal dilation when fully healedVaginal dilation when fully healedPO f/u then annual examPO f/u then annual exam

Prostate cancer in a transgender woman 41 years after initiation of feminization. Miksad RA. Bubley G. Church P. Sanda M. Rofsky N. Kaplan I. Cooper A. JAMA. 296(19):2316-7, 2006 Nov 15.

MTF MTF –– Penile Inversion VaginoplastyPenile Inversion Vaginoplasty

MTF MTF –– Penile Inversion VaginoplastyPenile Inversion Vaginoplasty

MTF MTF –– Penile Inversion VaginoplastyPenile Inversion Vaginoplasty

MTF MTF –– Penile Inversion VaginoplastyPenile Inversion Vaginoplasty

MTF MTF –– Penile Inversion VaginoplastyPenile Inversion Vaginoplasty

MTF MTF –– Penile Inversion VaginoplastyPenile Inversion Vaginoplasty

MTF MTF –– Penile Inversion VaginoplastyPenile Inversion Vaginoplasty

MTF MTF –– Penile Inversion VaginoplastyPenile Inversion Vaginoplasty

MTF MTF –– Penile Inversion VaginoplastyPenile Inversion Vaginoplasty

MTF MTF –– Penile Inversion VaginoplastyPenile Inversion Vaginoplasty

MTF MTF –– Penile Inversion VaginoplastyPenile Inversion Vaginoplasty

MTF MTF –– Penile Inversion VaginoplastyPenile Inversion Vaginoplasty

MTFMTF

Surgical techniques Surgical techniques very satisfactory very satisfactory –– AestheticsAesthetics–– FunctionFunction

Most difficulty is with Most difficulty is with ““passingpassing”” with clothes with clothes onon

FemaleFemale--toto--Male (FTM)Male (FTM)Minority(?) of GID patientsMinority(?) of GID patientsTestosterone significantly masculinizingTestosterone significantly masculinizing–– VoiceVoice–– Thyroid cartilageThyroid cartilage–– Hair patternHair pattern–– Muscular developmentMuscular development

Surgical options much less satisfactorySurgical options much less satisfactory–– Breast Reduction (Breast Reduction (““Top SurgeryTop Surgery””))–– SRS SRS –– Phalloplasty (Phalloplasty (““Bottom SurgeryBottom Surgery””))

Local or Regional Flap PhalloplastyLocal or Regional Flap PhalloplastyFree Flap PhalloplastyFree Flap Phalloplasty

–– Radial Forearm FlapRadial Forearm Flap–– Anterior Lateral Thigh FlapAnterior Lateral Thigh Flap–– Fibula Osteocutaneous FlapFibula Osteocutaneous Flap

Metadoioplasty (meatoplasty)Metadoioplasty (meatoplasty)

FTM FTM –– Breast ReductionBreast Reduction

MTF MTF -- PhalloplastyPhalloplasty

MTF MTF -- PhalloplastyPhalloplasty

MTF MTF -- PhalloplastyPhalloplasty

MTF MTF -- PhalloplastyPhalloplasty

RFF PhalloplastyRFF Phalloplasty

RFF PhalloplastyRFF Phalloplasty

MTF MTF -- PhalloplastyPhalloplasty

MTF MTF -- MetadoioplastyMetadoioplasty

FTMFTM

Surgical Techniques Surgical Techniques in need of in need of improvementimprovement–– AestheticsAesthetics–– FunctionFunction

Hormonal Influence Hormonal Influence ––pass well in clothespass well in clothesMost difficulty is with Most difficulty is with ““passingpassing”” without without clothes.clothes.

Fundamentals of Gender Fundamentals of Gender ReassignmentReassignment

William M. Kuzon, Jr., MD, PhDWilliam M. Kuzon, Jr., MD, PhDReed O. Dingman Professor of SurgeryReed O. Dingman Professor of Surgery

Section Head, Plastic SurgerySection Head, Plastic SurgeryUniversity of MichiganUniversity of Michigan