Fat Grafting + Revision Surgery {June 20th, 2016}

*** I never got around to making a formal update on this blog about how this revision and fat grafting went. I did cover some light details within the other online groups but I was saving this post to be the all inclusive space to talk about how those procedures went. I speak at great length about the FAT GRAFTING procedure and the end results since I know it’s often a hot topic with practically zero actual recorded experience/data on phallos.***

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Day Zero – Scrotal & Perineum Revisions & Fat Grafting

Perineum Revision: The perineal revision seemed to go really well initially. The area  had a nice clean straight midline incision that had the exact aesthetics I was hoping would result from this procedure. There was a small piece of vaginal tissue that was at the area which was revised, this was what was causing the moisture to occur. My body also grew a fair amount of granulation tissue, which is what the body creates in an effort to fill a wound or hole. This tissue can be painful, and it very much was for me. Sitting and weight-bearing on the affected area was really painful in the lead up to surgery. When I went in for my revision, Dr Chen cut out the granulation tissue, the tiny piece of vaginal tissue that was left over, and then closed the area using the healthy tissue around the affected area. I noticed soon after the revision that I was being poked  by some long-ish stitches or I had a hole that opened up. It clearly felt like there was an issue causing irritation. By about day 5 I crouched (in a careful position as to not put too much tension on the incision) over a small hand-held mirror and could see what looked like 2 teeny teeny tiny holes along the incision line. This was super discouraging as my biggest worry was that the area might reopen again. My surgery revision was on Monday June 20th, my post-op was on Thursday June 23rd. Dr Chen said everything looked great at that appointment. It wasn’t until 1 or 2 days after the post-op appointment that I could pretty clearly see the beginning of the holes. So I requested a second post-op appointment the following Thursday June 27th before I returned home. It was at that appointment that he confirmed I did have two small fistulas along the incision line.

{SIDE NOTE: Just to be clear, this was NOT a urinary fistula. Fistulas can be just an abnormal hole that forms along an incision like in this instance and have absolutely nothing to do with the urethra. It’s just a term that we so often hear when talking about these surgeries and most often they are in conjunction with urethral lengthening issues. So it seemed worth noting that there is no correlation to my urethra in this example.}

Dr Chen seemed pretty confident that these little openings would close on their own given the time. He gave me the standard instructions that you hear so often during these surgeries: “keep it clean and dry”. He said I could apply bacitracin to it if I wanted to. I asked about medihoney and he said if I wanted to try that, that I could. Long story short, I saw no improvement with either of those methods. In fact, the holes continued to get larger with time. To the point where I was able to fit a very very tiny ball of packing gauze in one of the holes which was slightly larger than the other. It was also really uncomfortable and painful to sit and put pressure on this area and I had long already returned to working 2 full time jobs (beginning 2 weeks post-op) which I’m sure didn’t help the healing process any. I reached out to a friend that is a previous patient of Crane’s that also had issues with his perineum. He told me about an antiseptic powder that he used that fixed his issue. No medical professional mentioned or knew about this powder. If you use it, you use it of your own accord, but seriously, it healed me!!! Within a week of using the powder I was more than 50% better and after about another week the holes had totally closed up!!! I have a tiny dip or divet from where the wound was if I really look for it, but the skin is completely dry and closed now. However, when I press on the area I do feel some tenderness and some minor pain. It’s my intuition that there is residual granulation tissue just under the surface that I might benefit from having removed. I think that the wound was open for so long while it was initially getting larger and the granulation tissue growth was inevitable. So I may have the area revised when I return for implants.

The powder that I used is called: Columbia Skincare Antiseptic Powder, First Aid For Sensitive Skin… This powder is seriously my BEST friend.screen-shot-2016-09-25-at-8-48-21-pmI’ve since told my PCP, and my surgeon about this product so that they might suggest it for others dealing this this problem. If you have a large wound, It’s probably unwise to apply it, but for smaller issues this really did the trick for me when nothing else was working. At the time, the smallest bottle I could find was a 14 ounce bottle through Amazon for close to $20, but now there is a 6 ounce bottle for just over $11. If you need a product like this, the 6 ounce will likely be more than enough. I have a TON left over from after my wound healed over. For reference, I was applying the powder to the affected area about 4 times per day in the beginning. If I noticed that the area didn’t feel completely dry and powdery then I applied more. As healing progressed I moved to 2-3x per day, then 1-2x, till I was forgetting to put it on because the spot wasn’t bothering me anymore. I was very generous with application, covering the entire perineal area, and as a bonus I actually used it on my scrotum as well and that just kept me feeling fresh and dry. The powder didn’t burn or irritate, using it was a pleasant experience and it felt wonderfully healing just to apply it!

WARNING: DO NOT, I repeat, DO NOT use baby powder

no-baby-powder
BAD IDEA

on an open wound. Trust me, I gave this a whirl when I was desperate and couldn’t find the antiseptic powder in any local pharmacies and was waiting for it to arrive in the mail. The baby powder felt like it was burning and irritating the area and only caused further inflammation and redness. So don’t do it. ONLY use a first aid product that is labeled for use on cuts or wounds. 

When I told my PCP I had been using an antiseptic powder on it she seemed really concerned, and it must have been because she didn’t realize just how different a standard baby powder is from an antiseptic first aid powder.

antiseptic-powder-uses
Indications for First Aid Use

She was firmly insisting that wounds shouldn’t be overly dried when they are healing because they will dry open. But I followed up with her throughout my use of the product and by the end she was a believer and asking for the exact info on it so that she could bring it up to her trans health team and potentially suggest it for use with others that report having a similar issue. My surgeon asked for the same information so that he might be able to recommend it’s use for others as well.

Scrotal Revision: So I had two small sebaceous (oil secreting) pockets at either end of the horizontal incision that runs most of the way across the scrotum from left to right. I was told this is a fairly common occurrence in that the incision line can collapse and thus create pockets. These pockets were collecting sebum that was similar to a cheesy buildup. I know, I know, it’s gross. But it’s actually the same build up that happens on all genitals, especially under unwashed foreskin and also in the vulva area. It’s a normal occurrence that regular healthy hygiene washes away on all healthy bodies. However, I didn’t even discover the pockets till I pressed on the skin around it and the pockets turned inside out, exposing the buildup. These pockets were cut out during my revision, thank god! I have had no further issues with them. I also had Dr Chen clean up the jagged scar line that the eschar created when I was dealing with my intense scrotal swelling post stage one. The scar looks much better now. There isn’t much more to report on this part of my revision, as it went smoothly and I didn’t have many concerns. I did have one area that bruised quite a bit, but there was no hematoma or issue, just typical post-operative bruising.

Urethral Cystoscopy: This procedure showed that I have a very slight ridge at the connection points of my natal urethra and the neo-urethra that was created with tissue from my RFF. Dr Chen said that a slight ridge is fairly common and that it’s actually really difficult and rare to connect the two without it resulting in at least a slight ridge at the connection points. This ridge is NOT a stricture. So I’m stricture-free! He saw no issues with the urethra, as it looked otherwise healthy and normal and he didn’t see any cause for my tiny bit of oozing and odor coming from my penis throughout the day.

Fat Grafting: Ok, so to get onto the good stuff!!! Man, I was super excited for the fat grafting (also called lipo transfer). I knew the likelihood of the fat dying off and my penis going back to it’s pre-fat grafting state was high, in fact I just expected that woud be the outcome. Nevertheless, I figured it was worth a shot. Dr Chen had only done 2 fat graftings before me (one he assisted on with Dr Crane, the other he did on his own). This is not a regularly done procedure, probably because it rarely sticks around with any lasting results. But I wanted to add to the numbers of guys that had tried this since it’s a much talked about topic and I was hoping to expand data collection on this issue even, if just anecdotal. I will say that Dr Chen basically suggested that I really didn’t need it and that my penis was fairly middle of the road in terms of guys who have a very deflated look and those that have very full plump, full penises. He thought I looked pretty average, and he said: “This is coming from a surgeon that is getting paid to do this procedure. If it were me I probably wouldn’t bother with it.” So although he was more than supportive of my decision and fully left the choice up to me, and also of course went to bat for my insurance to cover it, he didn’t really feel like it was a worthwhile procedure in my case or that it really had any long lasting effects in general. Which would align with the reasoning for him only have assisted with one and done one on his own. Certainly my experience of wanting a fuller, thicker RFF result can’t be uncommon since I see loads of guys with a similar body habitus as myself using their skinny forearms as donor sites too.

Fat Grafting Risks – I asked about the risks that came with the procedure and they are as follows: potential damage or injury of the nerves in the area where they are harvesting the fat cells from since they go in there with a long wand and jab it around all over the place in a fairly aggressive manner trying to suck up and collect fat cells. If you’re curious how aggressive this process is, feel free to drop “liposuction” into the Youtube search bar and you’ll a good idea. Spoiler alert: it’s NOT a very pleasant pleasant to watch, I’ve found myself cringing and feeling pain for the person on the table… So during this process nerve injury or damage can happen, and the thinner/leaner you are (which is true my case) the higher that small risk is… Severe bruising at the harvest site is also a common result of this surgery again, because of the manner in which they aggressively harvest the fat cells. Another risk is that you can end up with a lumpy aesthetic result where the fat is being transferred to. For example, some fat could attach to blood supply in part of the penis while others in that same vicinity didn’t attached and were reabsorbed, causing an uneven or lumpy aesthetic and/or texture… I asked about risks to the UL which was honestly my main concern. There is a very miniscule risk of urethral damage with this procedure. Teeny tiny, and I got the impression that it wasn’t something I should really worry much about.

Day of Revision Surgery & Fat Grafting (June 20th)- DAY ZERO I had my procedures done at Greenbrae Surgery Center and the actual surgery was no biggie. The nurses were lovely, especially Katrina who I adore, she’s the sweetest and a PRO!!! Dr Chen came in and spoke with me prior to being walked back to the OR. He told me that he would make two very small incisions on the tip of the head where he would insert the needle that would inject the fat into the penis. This angle allows the surgeon to drop the needle down into the full length of the shaft in order to disperse the fat cells throughout the entire penis. He said that the only complaint people have with these incisions is that they can make the penis head look like it has eyes. lol. But that the scars usually fade and blend in quite well. I wasn’t worried, my penis is fine with having eyes if it means he can be chubby – we talked, he’s cool with it. :o) The surgery went really well and when I woke up the first thing I did was of course pull the sheets down and pull the mesh underwear away from my waist to see my fatty. And seriously, he was FAT. Post Thanksgiving day feast, unzip your pants, FAT.

I was half awake but I was amazed at how when I wrapped my hand around my dick it completely filled up my hand and I actually felt like I had more than a semi, but a little less than a full erection. My dick wasn’t jutting out at a right angle from my body or anything, but it was as full as it possibly could be and I was so incredibly proud and glad that I had opted to have the procedure. One of the nurses in the recovery area was even complimenting me on my dick. Why, thank you! Urinating for the first couple of days took some effort. The combination of the increased level of fat as well as post-op swelling caused some compression of the urethra which I had predicted I might experience. So it took me sometimes a couple minutes to fully finish peeing. I was also trying to being careful because I was worried about straining or pushing and creating tension on my perineum revision.

POST-OP DAY TWO: By this point I was able to pee without any resistance issues, a good amount of the surgical swelling had gone down. I was careful to not have any firm pressure on the penis, I wore very light clothing and took off my underwear when I was sitting at home to let him be unencumbered. I didn’t squeeze or milk the shaft after peeing, as this can cause further trauma to the fat cells. I also used an electric blanket to keep him extra warm as an aid to help with assisting the vascularity connection. Remember, the only way the fat cells will stick around is if they are able to latch on to a localized blood supply. So knowing that blood vessels constrict with cooler temperatures and expand and open with heat, I assumed that keeping the area warm could only help the process of the fat cells connecting to a new blood supply a little easier.I really just applied the same logic as when I was in the hospital after stage one in February when they had the heater blasting on me for 5 days. Even still with all of these precautions I could already feel some places at the very base of the shaft where it seemed to be less full. I think this was likely the area to be affected the quickest since the penis is naturally bending with gravity at this area. And the pressure more quickly resulted in the absorption of the fat cells. The rest of the shaft also felt like it has decreased in size a small bit. This early on it might have just been the swelling going down. But if I had to guess I think by this time about 5-10% of the fat had already been re-absorbed. In terms of bruising related to the liposuction process, Dr Chen was SHOCKED at how I had a only a tiny slight tint of yellowish color that you had to really strain to see on my belly, my body took really well to the procedure. I also began taking arnica starting the day before surgery to ward off bruising and swelling. Whether it was a result of the remedy or not is hard to know for sure, but all the same it was nice not to deal with bruising. There was also very minimal tenderness in abdominal region as well.

TMI – MASTURBATION: I can’t really fully express the extent of just how much I was psychologically affected by this new fullness/firmness in my penis. I felt so much more confident and content with my penis, yes. But also, I felt virile. I’m fairly confident that I could have been capable of having vaginal sex with the amount of firmness that I had been afforded that soon out from the procedure. Anal sex, unlikely – It wasn’t that firm. But it really felt like a hard-ish dick when I touched it and it impacted my psyche and feelings surrounding my overall well being and satisfaction with my genitals and this overall surgical process to align my body with my brain. I couldn’t help but very gently jerk off with my penis in this state. I knew it was more than likely that the fat would eventually be reabsorbed and I really felt like I needed the experience of interacting with my body in this way before it was gone. And it…WAS…..AMAZZZZZING!!! Seriously, the amount of effort it took to reach orgam while getting a direct response from my hand feeling a hard dick, to my brain processing that as “I have an erection, I am aroused” to the point of orgam was a totally different experience than masturbating a much floppier soft penis. I realized how quickly and easily I am capable of orgasming when the opposite has been true for me most of my life. Things greatly improved with enlargement of my natal genitals from testosterone use. However, pre-stage one phalloplasty there was no getting around the fact that mental gymnastics were always, 100% of the time required to get me over the edge, because what I was touching and what I was feeling was not a full erect penis in my hand – and that’s what my brain needed… No matter what happened from here on out after this procedure, the fat grafting procedure gifted me my first experience of embodying and interacting with my adult, full-sized erect penis. It was FAR fuller and firmer than it ever was even immediately post-op stage one when I was still in the hospital! And obviously at that point so soon after surgery there is no masturbation happening anyhow.

1 WEEK POST-OP: By this point I’m guessing that about 20-25% of the fat had been reabsorbed. I was still using an electric blanket to keep him warm, avoiding pressure, and not milking him excessively after urinating. This was a depressing time for me. I could see that I was noticeably losing more and more fat each day.

2 WEEKS POST-OP: Close to 50% of the fat was gone by this point.

3 WEEKS POST-OP: Around 75% of fat had reabsorbed.

4 WEEKS POST-OP: Around 90% of fat had reabsorbed.

5-6 WEEKS POST-OP: 100% of fat appeared to have reabsorbed. Penis looked and felt identical to its’ preoperative fat grafting procedure state.

MEASUREMENTS: Overall, the fat grafting procedure temporarily added between a minimum of a 1/2 inch, but much closer to 3/4 of an inch of girth in many areas to my penis! This number might sounds small, but the experienced difference was actually quite drastic and very visually noticeable. From the sensation of holding him in my hand, to what I felt swinging between my legs, to my accentuated profile with clothing on and off.

CONCLUSION: Part of me wants to say: don’t waste your time with this procedure. The other part of me wants to acknowledge that totally amazing cohesive experience with my penis that this procedure made possible. I might be headed more in the direction of an inflatable erectile device had I not had this procedure done. There’s of course absolutely nothing wrong with choosing an inflatable erectile prosthesis, in fact I always thought I wanted one! I truly found it difficult to comprehend why anyone would want the semi-rigid rod when the inflatable cylinders functioned and replicated the process of a “natural erection” so much more closely. But as you go through this process you’re likely to have experiences that really morph the way you view and understand things – both for your body and others. Had I paid out of pocket for the fat grafting I’m sure I would feel drastically differently about it because the out of pocket cost if I’m recalling correctly was $4,000 or $5,000!!! So had self-pay been my way, I wouldn’t have ever been able to have this procedure. Nor would I really recommend it to someone that was self-paying. By the way, I asked, and fat grafting cannot be combined with erectile implant surgery. It could however, very carefully be done as a later, separate procedure.

If I remember correctly, Dr Crane reports that about 10-40% of the fat grafting actually sticks and that multiple rounds WILL or at least should eventually result in permanent gains. I will not be repeating this procedure so I won’t ever know. But I don’t believe that in the end I kept ANY percentage of the fat, I’m very certain that I lost 100%, as are the two other guys I spoke with. This is unfortunate, because if there was some way it COULD stick, this procedure could be a great erectile implant alternative given its capability of adding so much firmness to the penis. Especially since penile implants for free flap phallos still have quite a ways to go before they have higher satisfaction rates and lower complication rates, which are what lead many to forgo them altogether. The procedure itself added 4 tiny incisions to my collection of bodily scars. Two at the tip of the penis, and two on my abdomen very similar in size and shape to that of my laparoscopic hysterectomy scars. One of which Dr Chen was innovative with and placed at the end of my pre-existing scar from my delayed glansplasty incision harvest spot. I have to really look to find either of them. The 2 on the tip of my penis I never notice or care about. They’ve blended in tremendously and are already similar in shade to the color that I will be using to do medical tattooing on my penis once I’ve fully finished with surgery and am past my 1 year mark.

I think that about covers everything, but I’m happy to answer any other questions that you guys can think of that I might have missed.

 

 

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