Phalloplasty Consult w/ Dr Curtis Crane

At the beginning of this month (January 2015) I had a surgical consultation with Dr Curtis Crane to discuss my options for and his methods of phalloplasty. I’ve been researching lower surgery options for well over 10 years but I’ve only had one other consultation before now (Dr Toby Meltzer in 2013) and it was actually when I was considering doing meta as a stage one to see if it would be enough for me since it doesn’t “burn any bridges” in terms of moving on to later needing phalloplasty.

Just a heads up, this is going to be a VERY long post that covers EVERYTHING I spoke with Dr Crane about. I had literally pages of questions for him and I am happy to be able to share the information that I was able to ascertain because I know it was really crucial in figuring out which surgeon was the best fit for me and what procedures made the most sense given my desired outcome and personal preferences.

SETTING UP THE CONSULT: Back in late September 2014 I contacted Crane’s office seeking information about phalloplasty, consulting with him, and what his wait times looked like. His office took about 3 business days to get back to me, which felt reasonable for someone just seeking information. I was emailed new patient intake forms and was requested to fill them out and send them back. This same email listed out of pocket costs for phalloplasty ranging from $68,000 – $78,000 depending on the donor site of the flap and whether or not urethral lengthening is required. Also, if one requires a penile implant that would be a separate surgery that would cost $16,000 out of pocket.

I did inquire about both RFF (Radial Forearm Flap) as well ALT (Anterior Lateral Thigh Flap) phalloplasty and was informed that the BMI cutoff for the ALT phalloplasty is 35. If you desire urethral lengthening extended to the tip of the phallus and have a BMI higher than 25, you may require an extra stage of surgery. Hysterectomy must be performed at least 3 months prior to phalloplasty. Consultations with Dr Crane are $200 and can be done over the phone or in-person. You can make this payment by check or via PayPal. A phone or in office consultation is required before scheduling surgery.

I also asked about insurance coverage: “Dr. Crane is currently only contracted with United Healthcare, Anthem Blue Cross, and Kaiser Permanente as in network providers for bottom surgery. Our office is willing to work with other insurance companies, but first we need to verify that your insurance company offers trans benefits and that if a lifetime maximum exists, that surgery will be covered. If Dr. Crane is out of network with your insurance company, you will be required to pay the self pay surgeon’s fee up front prior to surgery and our office will submit for reimbursement with your insurance.”

The Consult: I chose to do an in-person consultation because I felt like I wouldn’t be able to get clear answers on the best graft site by just speaking with him over the phone. I am very lean so I knew I would be a great candidate (with my low BMI) for ALT if I wanted it but I needed to gather that information face-to-face. This just felt like too big of a decision to make over the phone. I needed to look into the eyes of the guy who was going to potentially do this surgery that I’ve been needing since I was 7. So I arranged for a quick trip out to San Francisco (I live on the east coast) with only two nights stay in the area at a Youth Hostel to keep the costs low ($30 per night). I booked my consult in the beginning of October 2014 and my consult was the beginning of January 2015 – It was just a hair over a 3-month wait period.

His office is located across the Golden Gate Bridge so I had to take a bus out of the city and then had under a 20 min walk to his office from the bus stop. His office has a relatively small but comfortable waiting room that had a couple other young transguys in it that were going over paperwork and waiting for appointments. I arrived about 5 minutes early and waited about 20 minutes in the waiting room and then another 40 minutes once I was called back and brought into an exam room. Oddly enough I felt good about waiting a bit longer for my appointment. It made me feel like he was giving his other patients the thorough time that they needed with him and would eventually get to everyone.

I had a very long list of questions for Crane so I’m just going to list the questions and then list what his responses to them. These are not all exact quotes from Dr. Crane, just the closest that I was able to remember in documenting our consult… Ok, let’s get to it…

Me: About how many phalloplasty have you done?

Dr. Crane: More than 100. I think I have most in the country right now, by A LOT.

Me: What are your thoughts on leaving the frontal opening verses closing it with a full vaginectomy and what are the complication risks involved with that and having full urethral lengthening?

Dr Crane: If you leave the vagina it’s fine, I think I’m the only guy in the country that will leave it and still do urethral lengthening. I’ve done it that way a lot. However, you have an increased fistula rate. Fistula is an opening from the inside of the urethra to the outside of the body. It doesn’t make you sick it doesn’t cause an infection, it just means you need another surgery to repair it if it doesn’t heal on it’s own. I’d say the risk of fistula WITH vaginectomy is around 10%, withOUT vaginectomy it’s closer to 25%.

Me: So worst case scenario you need another surgery, but in the end the fistulas are always able to be repaired, right? Have there been any cases where you haven’t been able to repair the fistula?

Dr Crane: No, I haven’t had that yet.

Me: Would keeping the frontal opening affect the positioning of the phallus? For example, would it need to be placed lower on the body if you did not do a vaginectomy?

Dr Crane: No, it wouldn’t affect position.

Me: So the only real visual difference would be in how the scrotalplasty is formed, right? Like it couldn’t be in one sac if there was no vaginectomy?

Dr. Crane: It would look the same. I make it the exact same way with or without vaginectomy. Maybe just a bit smaller so that I could close all the surrounding tissues.

Me: So you’re opening a new practice in Austin, Texas?!

Dr Crane: Yes! The end of this year. I’m bringing in a new guy, Mang Chen, he’s an amazing surgeon who did the exact same fellowship as I did. This year alone we have 150 cases booked already where I am teaching him my technique – where I will be working with him. Once I have him good and trained and believe me I’m not going to leave my baby in the hands of just anyone, he’s going to stay here (San Francisco) and I’m going to move to Austin… My goal in say 40 years when I’m on my deathbed, I want to be able to look back and say: I helped to make it possible for a transgender person to never have to leave their state for healthcare. I think that’s reasonable. The first goal was to have a successful practice. I’ve got that here so then I decided let’s go to the most conservative state and the most liberal place in the state (Austin) and make transgender care mainstream and from there it’s just going to propagate… And it doesn’t have to be all “Brownstein & Crane’s”, I just want this access for the community and this is the only way I see that happening. I could stay here in SF and just hide away in a successful practice and never promote anything. But since opening this practice now every ER doc, and family practitioner, and endocrinologist in the areas knows about what I’m doing. It happened here, it’s gonna happen in Austin. I know some people are worried about the change in the teams but really phalloplasty (and other surgeries especially lower specific) are not just a one man show. I’m the name on it but I’m only 33% of the team – the other 66% of the team I’ve been working with will still be here in SF and I will be training Chen to take over that 33%. So if you need to have me as a surgeon (starting next year) you can come to Austin and you’ll have that same 33% and the other 66% will be all people I’ve trained, or if you want to have surgery in SF, the same micro surgery team will be there and the other 33% will be Chen who is an amazing surgeon. Everyone has to start somewhere – in one year his name will be just as well known and in demand as I am.

Me: So what does your scheduling timeframe look like right now?

Dr Crane: November 2015 here in SF w/ Chen and myself, after that I will be booking the end of December 2015 or absolute latest January 2016 in Austin……. Are you thinking forearm, thigh???

Me: I’m still up in the air about that. As far as priorities go, sensation and urethral lengthening are neck and neck for me. However, I do want an implant. Being able to have penetrative sex is an absolute must for me and so I’m worried that maybe ALT is able to maybe sustain an implant a little better than forearm, would you say that’s true?

Dr Crane: I wouldn’t say that’s true. Well, the ALT is very girthy. If you are someone that wants a 6,  7,  7.5 inch phallus, then definitely ALT.

Me: I want 5 inches MAX!….. I have some burns on my forearm from when I was younger; I know they fall along where the tissue for the urethra would be harvested would that interfere with the integrity of the urethra?

Dr Crane: Those won’t be a problem.

Me: Does the forearm graft have to start right at the wrist or is it possible to go back a bit away from the wrist.

Dr Crane: You would shorten your length, if you wanted 5 inches we could come back a bit.

Me: *Touching my wrist* So this would be the base of the penis or the tip?

Dr Crane: The tip

Me: So, sensation differences between forearm and thigh?

Dr Crane: Forearm is better.

Me: As far as functionality of the donor arm, I’m wondering long-term what the functioning is like. I know initially, it’s going to be rough going but do you think that people tend to get 100% functioning of their arm back?

Dr Crane: Yes! I don’t know of someone who hasn’t. It’s like 4-6 weeks. Because we don’t take any muscle we just take skin and fat.

Me: Do you ever use Integra?

Dr Crane: We don’t because 1.) it really jacks up the price of the surgery 2.) it requires a separate surgery 3.) we take a thick enough split-thickness skin graft that it’s our opinion (mine, the microsurgery team and the Buncke clinic) that it doesn’t actually help at all and just raises costs and requires more surgery.

Me: So it seems like from what I’ve seen that maybe folks with a higher BMI have a bit more noticeable indentation on the donor arm from the graft – Would you say that it’s accurate to assume that since I have very little body fat my indentation might be less noticeable?

Dr Crane: Yes. So everywhere on your body you have skin, fat, muscle. What we take to make the phallus is skin and fat and then we take a split thickness graft (skin, no fat) and place that on the donor site. So it’s like skin right on muscle, then transitions to skin, fat, muscle. So if you have an extra centimeter of fat you’re going to have a centimeter higher divot – you won’t have to worry about that since your so lean.

Me: Ok, so then my worry becomes: Am I going to have a very thin penis?

Dr Crane: You would end up like this ***puts thumb to index finger in a cupped grasp shape with thumb and index finger a bit away from one another*** which seems reasonable for what you expressed in wanting in a 5 inch phallus.

Me: So, pre-lamination of the urethra?

Dr Crane: It’s like, the WORST idea! Monstrey, in Belgium, he’s done 600 phallos – He realized pre-lamination was horrible 10 years ago. I know Salgado is using this as a selling point but he’s a plastic surgeon, he’s never done reconstructive urology. I did 7 years of urology and any urologist will tell you pre-lamination is NOT a good idea. It hurts people and it’s not a standard of care. Unfortunately there is a lot of bad information spread among the community via blogs and there isn’t anything I can do about that.

Me: When you repair a fistula, from where are you taking those grafts?

Dr Crane: I usually do an adjacent tissue transfer of vascularized tissue and cover up the fistula.

Me: Do you ever use vaginal mucosa or buccal mucosa for repair?

Dr Crane: For phallo I don’t really ever use a graft. There’s enough vascularized tissue there that I don’t need to use graft. Vascularized tissue is always better than graft. When you take a graft from somewhere else and sew it in there is always a lot of scar tissue that builds up and really increases the risk of stricture, that’s why doing a pre-laminated graft is worse than using healthy vascularized tissue that’s attached to it’s own blood supply. You know how we take a skin graft from the leg and put it on the donor arm and it heals kind of gnarly? It’s because it’s a graft. Verses when we take all this tissue in a flap that’s attached to it’s own blood supply to make a phallus and it looks like regular skin. People look at the arm and think “burn victim”, but the phallus looks great!!! That’s the difference between a GRAFT healing WITHOUT it’s blood supply and a FLAP healing WITH the blood supply. It’s the same thing with pre-laminating a urethra. Every time you use graft you are just cutting out a piece of skin, slapping it on and crossing your fingers hoping it will reattach to a blood supply. When the blood supply is lacking there is a lot more scar tissue that builds up and it becomes thick like concrete, it’s really hard. So EVERYTIME graft is used it’s going to heal that way. Verses when you bring a blood supply with it like the RADIAL forearm, (it’s named that because of the radial artery) it heals great! So when you have people suggesting that it’s much better to use a graft, a pre-laminated graft… It’s just insane. Why are you going to build the most important functional part of this penis out of something that’s going to heal worse?

Me: Wow! That makes SO…MUCH…SENSE! Even though pre-lamination wasn’t something I was sold on, I was open to it if it truly was the best way to go and would reduce complication rates. I had been under the impression that this was a new technique, not something that had been tried long ago and tossed out because it hadn’t yielded a good outcome. I don’t see how I could pursue having a pre-lamination done after hearing that explanation – that was really informative……. As far as blood loss goes? Do people ever bank their own blood prior to surgery?

Dr Crane: I’ve transfused maybe 3 or 4 people out of 100 and those 3 or 4 were very early on in our first 15-20.

Me: As far as the insurance companies that you are contracted with currently – do you foresee those changing when you move to Austin?

Dr Crane: I’ll only add more. Because they don’t care what location I am in, they just look at the name.

Me: As far as the deepithelization/de-nuding/de-gloving of the clitoris, do people say that they still experience (although no longer a visual change in the tissues since they are inside the base of the phallus) the sensation of becoming erect? That sensation of growing and thickening is something that I would really hate to lose.

Dr Crane: That’s a good question, I haven’t asked. It would stand to reason that they would though because I leave all that erectile tissue. I only remove the thinnest layer of skin so that there is no sebaceous cyst that forms. But I specifically take the thinnest layer of skin, and leave all the erectile tissue and all the nerves just below the skin so that you have a really erogenous spot.

Me: The skene’s glands and bartholins glands, do you leave them intact?

Dr Crane: I leave them. I leave all the glands that I can so that there is some ejaculation.

Me: Do you do an Allen test to confirm if someone is a good candidate for RFF?

Dr Crane: Yeah, we can do that…. You know it’s like less than 1% of the population that has a bad one. ***Test showed positive signs for me being a good candidate***

Me: What’s the incision like for implanting the erection pump/rod?

Dr Crane: It’s real easy, I go through a previous incision that’s already healing at the base of the phallus – no new scars.

Me: What are you’re complication rates looking like for pumps?

Dr Crane: I’ve had about 2 infections, and 1 erosion. Pretty low, about 5%, maybe 10%.

Me: Do you wrap the pump in anything?

Dr Crane: Yes, it’s gets wrapped in a Gortex sheath.

Me: About how many years do you think a pump will last?

Dr Crane: At centers around the world that do free flap phalloplasty they say that a pump will last 3-5 years. The rod however, will last 10, 15, sometimes 20 years. For that reason most of my patients opt for the semi rigid rod because they don’t want more surgery.

Me: On an RFF would the main incision down the phallus be on the underside?

Dr Crane: Ventral, yes – AND for the ALT, as well. We used to do it for the top and bottom on the ALT because we had concerns about the urethra, but we made some adjustments and we were able to modify so that it’s only ventral.

Me: When you take a split-thickness graft (the one that will eventually cover the phallo donor site) typically the hair follicles don’t come with the graft, correct? Even though you said you take a substantial graft to cover the arm (for RFF) or leg (for ALT)?

Dr Crane: No, the hair stays on the leg.

Me: Can you construct a frenulum during glansoplasty?

Dr Crane: We always try, but it depends on how it scars and flattens out. We can control pretty much everything in the operating room, but the real complications come from how people heal. Sometimes we make a REALLY nice glans, and the whole thing is lost 9 months out. Fortunately that’s only about 10% of the time. Usually by 6-9 months if it’s still there then it’s gonna stay.

Me: If you want a REALLY well define glans, do you suggest waiting to do that at stage 2 with the implants?

Dr Crane: We’ve gotten really great results with doing it at stage 1. I’ll do it at stage 1 and then if someone needs a touch up, I’ll do it again. That way it gives me an opportunity to do it twice.

Me: So there’s no benefit to waiting to do it at stage 2?

Dr Crane: No

Me: What can you tell me about likelihood of shrinkage. Like losing length or girth?

Dr Crane: I’ve only had 1 patient really complain about that. When I looked at pictures though it looked the same to me.

Me: When you measure how long the phalloplasty is going to be, like I said I want 5 inches, do you measure right on the arm itself? I ask because I know depending on where you put a ruler on a penis be it along the top or underneath you get a different measurement.

Dr Crane: Yes, we measure on the arm.

…………

Well, that’s the bulk of what I can remember and in looking back at the questions I had printed out to ask him. I really wanted to go as in depth in possible for a couple reasons. First I know how important it’s been for me to get answers to these questions but sometimes when you hear other people’s questions you get answers to things you didn’t even think to ask and then those questions/answers will generate new questions for you all together. And it’s been my goal for myself to really research and look at this from every angle possible so that I am as prepared as possible and will have the least amount of surprises post-op. But also, I imagine it would be easier on Dr Crane (and any surgeon) if their consults weren’t filled with answering the same questions over and over. It seems like that precious consultation time could be spent on more personal questions that aren’t so overreaching and relate to everyone or a general technique that’s performed.

I hope this has been helpful to someone out there.