Stage 2 – Surgical Prep

~((( JUST A REMINDER: While these prep instructions may reflect the instructions of other surgeons and teams, these directions are specific to patients having any form of implant surgery (erectile and/or testicular) with Dr Crane & Dr Chen. )))~

There is some body preparation needed for stage two RFF (Erectile & Testicular Implants) however it’s very different from the body prep that is needed prior to stage one. There is no need for a bowel prep this time around!!! Hooray!!! However there are two things that were not required for stage one that are required in preparation for implants.

Prophylactic Antibiotics – Two mornings before your surgery you start an antibiotic called Bactrim. It’s a twice daily 10-day course. My surgery is on the 11th, so I start the antibiotics on the 9th which allows 2 full days doses and then one pill the morning before surgery.

Hibiclens Soap or Chlorhexidine Gluconate Wipes – This is an antimicrobial soap or wet wipe that can drastically reduce your chances of acquiring a surgical infection. You’ve got a couple options depending on which you’d prefer to use. Keep reading for additional info that might help you decide between these options.

What is Chlorhexidine Gluconate? Chlorhexidine Gluconate (CHG) is an antiseptic that helps reduce bacteria that can cause infection MRSA. Sage’s 2% CHG cloths contain FDA-approved formula that stays on your skin where it’s needed most. Ordinary bottled CHG soaps require rinsing in the shower. With Sage 2% CHG Cloths, none of the bacteria-fighting ingredient goes down the drain.

Further reading comparing the two if you’re a nerd like me —>  GEEK OUT

You can find SAGE Cloth wipes HERE

The Hibiclens soap you can find at any drug store, large grocery store, or Amazon.

EXTRA SKIN PREP & CLEANSING INSTRUCTIONS FOR THE TRULY OBSESSIVE (this is a 5-day prep pre-op and was not required by my surgeon but is by some other teams and for some other procedures) I don’t know that I’d use the CHG for 5 days prior, but the instructions to use a thin layer of Mupirocin (Bactroban) just inside the nose is a really good preventative, even if only applied the night before and morning of surgery – as staph likes to live inside the nose.

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The following are other items/supplements I chose to add into my recovery regime.

Homeopathic Remedies: I used these remedies for stage one as well and figured it couldn’t hurt to add them in for stage two. The suggested dosage is 5 pellets, 3x per day for each of the remedies. NOTE: 1.) Don’t touch them with your fingers (it affects the potency) tip the bottle upside down and twist the cap… 2.) Let them dissolve under your tongue, chewing/swallowing exposes them to stomach acid which affects potency… 3.) Take them one at a time, don’t dump all 3 different remedies under your tongue at once, again this can, you guessed it, affect potency.

Arnica Montana(30c): Helps with bruising, swelling, and pain

Staphysagria(30c): Helps with the healing of surgical wounds

Graphites or Thiosinaminum(30c): Helps reduce scar tissue.

 

Ice Packs (Thera Pearl): I bought two of these rectangular ice packs in preparation for surgery because I’m anticipating lots of swelling, especially in the scrotal region. I found them on Amazon as “add-on” items. They also come in a round option as well, which I imagine would probably be great for balls!

 

Mesh Underwear: Always a good call for a few days when things might still be oozing and bloody. You can also ask the nurses in the recovery room after surgery if they’d be kind enough to send you home with a few pairs, they’ll usually oblige.

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X-Top for Men: These are incontinence sheaths designed specifically for men. You can visit their website and request a sample of each of the three absorbencies to be sent to you absolutely free! The reason I thought to get these was because post erectile implant, while you’re still healing it’s advised that you not milk and shake the penis after peeing, or at least do so with extreme caution as this aggressive movement could cause the mounting point at the pelvis to break away. I figured this might be a good option to use that would protect my clothes and absorb odor. They are pretty pricey though,  so I only got the 3 free samples. Toilet paper will do just fine after I use up these freebies.

 

Edibles (Pain Management): I’ve historically had a REALLY difficult time stomaching any type of narcotic,deb483f7-5131-4b50-a3ca-dcb33f8a702f even with the use of antiemetics. For this reason, in addition to wanting to try something more natural, and because I heard more than a few guys suggest it, I decided to try edibles. If you’re not familiar, think weed brownies. The location where I’m staying in California is about a 4-hour drive from Oregon where they have legal recreational use of cannabis. So I took a drive up there to pick some up. The hope is to be able to strictly use edible THC and CBD to manage pain post-op and completely avoid nausea.

 

COLUMBIA ANTISEPTIC POWDER: I had SUCH good luck with this miracle powder completely healing a hard to heal wound in the past. I decided to have a minor revision on my perineum again and I wanted this close by to use prophylactically. If you are combining your implants and/or erectile device with any kind of perineal revision or procedure, I really can’t recommend this powder enough. Some wound beds need moisture to heal but the perineum is different, it needs to be kept dry.

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FLEXIBLE TAPE MEASURE: Also, really unrelated to recovery, though it could be used to track swelling. I brought a tape measure to see just how much girth the gortex and erectile rod will truly end up giving me.

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3 Months Post-Op RFF Phallo

Yesterday, Thursday the 5th technically makes 13 weeks since surgery. I had surgery on February 4th, 2016, so I’m going to try my best to keep doing monthly updates around the 4th of the month rather than keeping track of weeks from now on. I can’t say how lengthy I will continue to make these posts, but I’ll do my best to keep them informative and detailed. At some point I’m likely to switch to posting every 3 months and then eventually only when something worth updating about occurs.

In the meantime:

Things are mostly going well. I’ve been back at work for a month and I’ve been managing, again, mostly well. Surprisingly what I thought would be the biggest challenge (my arm) is the least of my worries. My hand strength is getting better all the time and more than enough for all basic daily personal and work tasks. My wrist mobility is nearly 100% what it was prior to surgery – however it does FEEL stiff, but I can still get almost equal flexion compared to my other wrist. Heavy weight-bearing with my palm flat down and my wrist bent is the most uncomfortable position. So while push ups are certainly possible and have been for many weeks, it’s not something that I’m doing regularly. Weight-bearing in that position over flexes the joint and it’s uncomfortable. I’m still continuing to do O.T. on my own at home when I think to do exercises and stretches and I’ve been able to achieve satisfactory results this way.

FOREARM/DONOR SITE: The scar continues to look more and more blended in with the surrounding tissue color. The color actually looks even more blended and natural in person, the photo doesn’t do it justice. The light brown spots corresponds to areas where the graft had some minor slough. The graft just didn’t take quite as well as the pinker areas. I’m sure eventually it’ll all blend in quite evenly.

Forearm 01.JPG

I have noticed some progression in scar edges flattening, although the main ridge that runs radially where the two skin grafts were stitched together continues to remain more pronounced than the other edges. I wish I had pressed on this ridge line earlier to help flatten it but I did have some pieces of the healing graft that looked to be pulling away from where it was suppose to be and so I literally let the ridge dry up because it was mushy and too wet at one point from too frequently changing the xeroform. I figured at the time that if it dried up more that it would stay in place and not pull away from the wound bed. I massage this ridge pretty much daily now to aide in breaking up scar tissue and help with flattening the ridge – the issue though is with the sensitivity that I have radially near the wrist. If I take my index finger and firmly tap on this area, or god forbid accidentally bump it on something like I did the other day, the pain can be mildly uncomfortable to intensely painful depending on how hard it is struck. I honestly don’t even want to THINK about getting tattooed in that area. YIKES! Maybe in time this will calm down in the same way that the hypersensitivity along the back of my hand did. But I was warned by the hand therapist at CPMC, that Dr Safa advises against tattooing in this specific area because you can damage the nerve and cause a lot of issues.

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HAIR GROWTH: This is specific to the hair growth that I’ve experienced on the healthy non-grafted tissue on my donor arm. If you’ve ever had a cast or worn a compression sleeve on your arm you may be familiar with what can happen to the hairs underneath. I’ve been told that it’s friction that can cause it, but areas that are covered with a tight sleeve or cast for many weeks often sprout new coarse hairs that didn’t exist before. It’s a temporary phenomenon and it’s gone away in my previous experiences with it but I thought I would share a few photos showing the occurrence. The following photo is of course the bridge of my donor arm. The bridge is the area where I’m experiencing the excess hair growth since it’s the only area that’s covered with the sleeve that is still capable of growing hair:

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And this is my non-donor are in that same exact area. The hair is much finer and more sparse. Also keep in mind that I had almost completely cleared my donor arm in that area where all the hair is growing. This is a perfect example of how the body can trigger inactive or dormant hairs to start growing in certain circumstance. And if friction on the skin can cause this, it would stand to reason that that is the reason why even guys that clear the fine blonde hairs from the inside of their forearms can still have substantial hair growth show up in their urethra post-op.

Non Donor Arm.JPG

Here’s a side by side:

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DONOR ARM LEASH SITE: The leash that they harvest from the forearm above the flap site is doing better than ever. The scar is still pink and dark-ish at times, but adhesion was the big issue here initially. I am no longer having any issues relating to adhesion that bother me. Certainly there is still some existent adhesion that I notice when I am moisturizing and massaging the area, but I no longer feel pain or discomfort when extending my arm or reaching for things. It was probably at about the 6+ week mark that that sensation completely went away. It didn’t just happen on it’s own, I really worked at it to relieve the tension with massage, and stretches. Be proactive, push through the discomfort and eventually it will dissipate.

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SELF-CARE: I’ve been moisturizing my scars with shea butter for about a month and I’ve been happy with the outcome.My forearm graft feels softs and healthy. It does get dry easily and 2x daily moisturizing is most ideal, but it doesn’t always happen. At about the 2 month mark I did become a bit more lazy with upkeep on things such as my daily rituals of moisturizing all my scars, massaging, always wearing my silicone patch and sleeve. I started not being quite as vigilant and obsessive about all of it.

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THIGH: My thigh still gets really itchy at times. Interestingly enough weight-bearing activities can increase the itching sensation. It must have something to do with more blood flow happening in the area, but it’s odd none the less. I’m moisturizing that area at least 1-3 times per day. Since I switched to the shea butter it seems to lock in the moisture for longer than the Eucerin did.

Liquidy sperm shaped Eucerin from last month: (photo 04/08/16 – scar is darker)

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The Eucerin was nice though because it was a quicker and easier application – whereas the shea butter is a very firm/harder substance and it takes a bit longer to warm it up on the skin before it will rub in and absorb.

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So I tend to probably use it a bit less frequently since it takes longer to apply. Either way, the scar appears to be doing well and continues to fade. I have gotten some ingrown hairs a few times that resulted in a pimple forming. That’s been slightly annoying but seriously a non-event. I just pop it, free the trapped hair and move on.

This is a photo of my leg this evening immediately before the shea butter application:

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And this is after 3 minutes of moisturizing and massage – there is quite a noticeable difference in the shade of the scar afterward:

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Here’s a side-by-side for easier comparison:

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HOOK-UP, GLANSPLASTY, SP SCAR: All three of these incisions are still continuing to heal well, with no issues or anything remarkable to report. Since last month I think I’ve noticed more progression in terms of scar fading with the hook-up scar:

Hook up.JPG

more so than the glansplasty scar. These incisions I admit to being WAY lax about tending to and I very rarely apply lotion to them or massage them – maybe just 1-2 times per week.

Glansplasty & SP.JPG

PAIN: I continue to experience mild, to fairly intense building pressure and pain in my groin when I stand for long periods of time. It’s most inconvenient and annoying when I’m at work and sitting and/or lying down wouldn’t be appropriate. This sensation feels like really extreme blue balls – like blood flow is just increasing and increasing and as though I am getting a rock hard erection but one that just throbs and aches. That’s the best way I can describe it. I also often refer to it as my balls having a migraine. It’s not a pleasant sensation. I’ve been experiencing this since the very first time I stood up at the hospital and it has been by far the most painful thing throughout all of this. Initially I couldn’t stand for more than 30 seconds without breaking out in a literal sweat because the pain was so intense. Gradually though, the time frame I could stand without pain increased and I could make it to the bathroom, to the kitchen to grab something then hobble back to the couch. Always once I am in a scooched way back sitting position where I’m able to lean mostly reclined, or fully laying down, then immediately the pressure/pain is relieved. I’m really hoping that in another month or two this experience will be gone. This pain and my v-nectomy site are the main things that feel like they are keeping me from being all that active right now.

PERINEUM: *sigh*… Ok, the hole is honestly doing WAY better than it was when I first got home from California,  and then a couple weeks after being instructed to pack it with gauze it really started doing much much better. It’s so shallow and small now that the gauze falls out immediately. I really wish Crane has instructed me to pack it when I saw him at my last post-op appointment and had him look at the site. As it stands, I didn’t end up making an appointment to have it looked at locally till a month after I got home because I just didn’t know any better. I figured I would have been told to pack it if the wound needed it. I would have really benefitted from packing it starting at just  a couple weeks post-op, it might have not even gotten to the size that it did, even though it was still fairly small and I would have been more comfortable in the meantime… Right now the tissue is 90% healed with light healthy pink tissue, but there is a noticeable divit where the skin dips into a crevice. The crevice has healed tissue on the inside, but to me it looks like a mini shallow vagina, which is just not ok with me. This divit is what I am seeking to revise. I want it closed up and brought back to the midline like a typical male perineum. I am currently trying to book surgery with Dr Nikolavsky in Syracuse, NY. I was going to have the procedure done locally in Boston, by a uro-gyn, but there is a secondary issue that I  am still having with my scrotum that the uro-gyn is not comfortable addressing.

SCROTUM: I continue to have an existing “pocket” of thin sebaceous tissue that previously functioned as the inner tissue of my labia majora. This specific tissue is sebaceous in nature, which means that it secretes oils and fluids. The inside of the labia majora is a thinner/wetter skin. It also can build up the same kind of “cheese” (sorry, I know it’s gross) that is especially produced in the foreskin of uncircumcised natal males. So no matter how much I keep this area clean and dry, it just produces more wetness and creates smegma over the course of the day. The pocket is just large enough to fit the head of a q-tip into and I honestly didn’t even know it existed till I got really up close and personal with my sack at around 4 weeks post-op and was horrified to find a pocket of smegma that had been growing there for weeks. There is another tiny missed piece of sebaceous tissue on the opposite side of my scrotum, however it’s  much smaller, about 5% of the size of the larger pocket… I had a follow-up with the uro-gyn in Boston about surgically closing the v-nectomy opening and also asked if he would be able to fix the pocket in my sack, although I was fairly sure he wouldn’t be able to. He looked at my scrotum and didn’t feel confident in messing with it since it was closer to my UL than he felt comfortable cutting into and he wasn’t sure about what was just under the skin in that area. I completely understand and truly appreciate him being honest about his comfort level. I’d rather know that a surgeon isn’t comfortable with doing a procedure rather than have him try to do something unfamiliar and then the outcome be that I wind up with another complication or an aesthetic result that would leave me disappointed. For those reasons I’m seeking out a revision of both my scrotal and perineal issues with Dr Nikolavsky in NY. I’m hoping for a date later this month or the middle/end of June… I have the option of returning to CA to have either Crane or Chen do the revision but it would cost me a pretty penny to fly out there, deal with local transport to and from the office, hospital, lodging, airport, and other expenses. My other option is that I could just wait until stage 2 to have the revisions done, but I really feel like I need to have it taken care of sooner than later, because I’m pretty uncomfortable.

ELECTROLYSIS: I just resumed electrolysis post-op for the first time on 04/28/16 (one week ago). I didn’t feel any pain associated with the hair removal, so I’ll be grateful for that. I had a 1 hour treatment and 100% of the hair was easily treated within that 1 hour session. The majority of the hair that is growing on my penis is on the UNDERside, on the lower right quadrant if I look down. There are a few stragglers here and there on the top and all over the shaft, but most is on the underside. I did about 11 months of hair removal pre-op (started with laser and then finished up with electrolysis). If I had it to do over I would have ideally had a solid 18 months of hair removal done prior to surgery. It’s not a big deal that I’m finishing up post-op, but it’s not all that ideal either. Also, I do have some hairs that I can see growing out of the tip of the UL. I debated about what to do with these hairs for a while. At first I was just trimming them VERY carefully, with very accurate small medical scissors. I also discussed the potential of using nair (in the UL, and peeing it out) with my electrolysis. I know a handful of guys who have gotten the go-ahead from their surgeon to do this and have tried it. The first time I heard this technique was being used inside the penis I’ll own up to being pretty shocked and horrified. But I guess with all things lower surgery I’ve just gotten used to the things that we sometimes have to deal with. So understandably when I mentioned the hairs sprouting out of the tip of my dick and the possibility of squirting Nair inside my penis, she had a similar reaction that I had when I heard about it initially too. She said that some people report burns just when using it on their legs or other body parts and that ingrown hairs are common too. She suggested that tweezers instead. My main worry is that tweezing might lead to ingrown hairs, which can lead to swelling at the site, which could potentially lead to a urine blockage… Alas, I eventually made the decision to tweeze them out. No issues thus far, although it’s of course early on and it’s only been a few days – but I’m relieved to look down at my dickhead and not seeing hairs sprouting out of my urethra.

SENSATION: I actually just noticed some sensation beginning only a few days ago and it was completely accidental. After my electrolysis appointment I was rubbing zinc ointment onto my shaft as directed to soothe and protect the skin post-treatment.

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I noticed an odd twinge of sensation and assumed I must have tugged at the base and that was what I was feeling. However, after more observation and experimentation I have been able to duplicate the sensation while mobilizing the base and not creating any tugging motion. I can firmly squeeze or pinch the head of my dick and when I do, a zap of sensation shoots down and is felt in my buried dick. I can also kind of roll my shaft in my fingers, pressing firmly into it and this creates a similar sensation, again, felt in the buried anatomy. I wouldn’t say the sensation I’m feeling is necessarily pleasurable. Although it’s certainly psychologically exciting to know that the nerves are steadily working their way through the highway sheathes, growing in, and making connections. Keep on networking, buddies! Keep on networking!!! I’m mostly shocked because I had imagined that the sensation would begin at the base and I would feel it there for a while and as time passed it would slowly make it’s way up the shaft. Currently though, I can trigger this sensation along all points of the length of my penis. It’s certainly not enough that I could orgasm from it, but still it’s a step in the right direction. There are multiple types of sensation (tactile, protective, erotic, hot/cold, wetness) so I still have a long while to wait as the nerves keep on doing their work! But as it stands, every day since discovering this I’m noticing it more and from less and less pressure. Even gently pulling him out to pee I feel it!

ORGASM: Orgasming has still been a fairly regular occurrence and was possible since right before week 5. I’m pretty sure I explained all that in detail in a past post, so I won’t really get into it here. But it’s primarily a tugging or pumping/bumping (into the anatomy at the base) that allows for orgasm to occur, at least for me. Currently the build up to the orgasm is much more psychological than it was pre-op, but the orgasm itself is easily just as strong. I keep telling myself that it only gets better from here on out, so that’s comforting to know. While I’m glad I haven’t lost my orgasmic ability, it’s certainly more work to achieve orgasm and the time during the build up to orgasm can actually be just as great if not equally amazing to climax. So that’s kind of frustrating to not have access to the intensely sensate buildup right now in the way that I could access pre-op. But this is a process, and time really does make a big difference. The odds are in my favor that I will eventually have pretty amazing sensation in my shaft and I believe that that will make all the difference for me once that occurs.

IMPLANTS: I still am on schedule to have implants in October of this year with Chen in San Fran. However, I am concerned about the current options available in the states for an erectile device. If I had access to any implant I really think I would go with the new Zephyr rod. My reasoning being low maintenance, few parts to fail, and I like that it would fill out my penis more 100% of the time rather than a rod that would only fill it out while inflated. I’m a skinny dude and my penis is certainly on the thinner side. I would like an overall thickening to my profile and I don’t think that the current options for rods available in the states would at all meet my needs. If given the choice between rod or pump, I’d choose pump. The overall shape and thickness of regular rods compared to the Zephyr looks wildly different. I like that the Zephyr model has the defined glans stopper at the tip and also that the overall girth of the implant seems to be thicker which I think would add to the density of my penis. I think it’s unlikely that the two Zephyr models will be available within the states anytime soon. So come October I’ll have to decide between getting the inflatable plus one testicle, or holding off on an erectile device for now and just getting my testicular implants. Immediately after surgery and for the first 6 weeks afterward I loved the thickness I had. It didn’t even look all that swollen, it just looked like a reasonably thick cock and I didn’t think I had any swelling there to go away. As the weeks progressed though I did notice that the girth decreased. It’s not a huge deal, but I would feel more confident with a bit more thickness happening all around, and not just during an erection.

PEEING: Urination is still going well. At one point last month I was worried I might have a UTI. I’ve never had one before so I only have a vague idea of what sensations to look out for. I was having a bit of discomfort close to the kidney area during the first pee of the day. This can be a common sensation if you have a UTI. So I made an appointment with my PCP to have a urine culture done. Everything came back with no issues. Then a couple weeks ago I started noticing a strong odor coming from my penis. Smelled like… ugh, ok, it smelled reminiscent of potent vagina that hadn’t been washed in a couple days. I reached out to Crane and asked if I could go on a course of Bactrim and described the odor. He suggested I go get a culture done because Bactrim doesn’t work on everything. I emailed back and said I had just had a culture done recently and it was normal and asked if I could just try the Bactrim anyway… Buuut, I never heard back from him. This was last Friday. In the meantime the odor has mostly dissipated. I haven’t felt the need to contact him or the office about it currently, but I was kind of annoyed and felt ignored that there was no follow-up after that.

PEEING HACKS: Otherwise my stream is strong and straight. If I’m at home or walk into a bathroom that is a single stall or that no one is it, I will tear off a small piece of paper towel and then after peeing use that to dab the tip of my penis and soak up a couple drops that would otherwise end up in my underwear. It’s not a big deal if they up in my underwear, but I feel drier and cleaner blotting the tip. I can’t tell you how often I see bio guys come out of the bathroom and they are leaking through their underwear and pants in a single circle drop at the head of their penis. I’d rather not be that guy if I can avoid it. If you choose to use this method, just be mindful to not drop the piece of tissue or paper towel in the urinal!!! Urinals can’t flush solid material or waste. I know, this might sound like a really obvious and basic concept, but I’ve accidentally done this a couple times because it’s habit for me to flush the single square of toilet paper that I use at home when standing to pee, in the toilet after I’m done. Muscle memory WILL make you drop it in the urinal! So be careful – you don’t want to be that guy either! Clogged or overflowing urinals are a pisser. Just discretely put your penis back in the stable and when you walk to the sinks to wash your hands you can toss it in the trash. No biggie. I’ve discretely observed men in restrooms for over a decade and plenty of guys do this. I tend to notice it more as a practice used by older gentlemen, but it still happens. No one will think or say anything about it.

WEIGHT: I probably lost like 10 lbs immediately following surgery. My appetite was terrible and I was nauseated just thinking about trying to get food down. The food issue alone was one of the BIG reasons I was so grateful that I had someone there to help with caretaking. Many days there was only one or two things I could even fathom being able to stomach and sometimes it was not a food I even had in the house. So having someone to walk down to a local store or make some food that was already in the house was a huge lifesaver. I honestly would have probably eaten 75% (and I was already eating so little) had I not had a caretaker. And adequate calories and protein are really important when you’re trying to heal. Currently I have the opposite problem now that I’ve long gotten my appetite back but still am not at the activity level that I was prior to surgery. I’ve probably put on 8 – 10lbs over my regular pre-surgery weight, which is a lot for me. Weight gain is common after major surgery. I’m trying not to let it get me down, but it does contribute to not really feeling like myself.

PSYCHOLOGICAL CHANGES: I really feeling like in a lot of ways I’ve been reborn. There is both deep joy and also some angst in that experience. I feel really grateful for having had only very minor hiccups along my recovery so far. But I also have worries at times that are not uncommon to most if not all men at some point in their developmental stages and throughout life. Like: is my penis big enough? There are times when I have asked myself if I chose the right donor site… I ask myself a lot of questions in life and so acknowledging that question and curiosity doesn’t mean that I have regret. Rather, I think it is important to bring up because if you were someone that is currently or was previously swaying between donor sites at some point in time, that thought or “what if” curiosity could still linger at times post-op. I’m not going to pretend it’s a thought that doesn’t exist because that only gives it more power. I freely admit that I would have and still do wish I could have known exactly what my penis outcome would have been like (functionally, aesthetically, sensate-wise) using every single donor site possible. Who wouldn’t, right?!?! Donor site is a big decision. I think it’s natural to want your penis to match as closely to the image you have in your mind as possible.

I love my penis, but I do also wish that I ended up with a bit more length and girth. And while I don’t get mad at myself to wondering what outcome I would have had with say, ALT, I try not to linger too long on these questions… In the same way that I feel I am on the more modest side of the scale of penis owners, there was potential for the complete opposite to be true for me and feeling uncomfortable with far too much girth for my preference. My body could have also reacted negatively with the use of a different donor site and I could have had major complications. So there’s really no way of knowing. I say all this because it’s a mental process that does feel in some ways that it’s landed me back in that adolescence phase that starting T does to us. Relearning a new body, feeling a bit awkward at times while we adjust to it, and relearning and experimenting with how to interact around and with others in both platonic and sexual exchanges.

6 Weeks Post-Op

Well, another milestone. Today makes 6 weeks since I had RFF with Dr Curtis Crane in San Francisco, CA. Things are coming along well. I did make a brief post when I had noticed that my small urine leak which was coming from my scrotum, closed up. Since my last big post at 4 weeks, the biggest changes have been that my scrotum stopped leaking (both urine and other fluids that were draining), and my SP (supra pubic) cather was removed. Those two things were HUGE for me. Honestly, since the time I started plugging my SP (at 13 days post-op) and was able to ditch the catheter bag, having a SP catheter got A LOT easier. It wasn’t a big deal – it wasn’t exactly ideal either, but it was manageable. It was mostly just annoying, and thankfully not painful. But still I did have a constant worry of something accidentally getting snagged on my tubing (even though it was under my clothes), or accidentally tugging on it with my hand when I would reach into my underwear to adjust my guy (that WAS painful). There was also general tenderness around the opening where the tube entered the body and the need to clean the opening a couple times per day so the scab didn’t take over. So while it wasn’t a huge deal to have the SP, and I mostly tried not to think about it, it was an utter relief to have it removed.

Before SP Removal.jpg

I felt human again afterward. From the time you arrive at the hospital the morning of your surgery and get that first medical device hookup up to you (usually an IV) you’re connected to a ridiculous amount of stuff – both devices and bandages, for many weeks. So as you shed them, one-by-one it’s like coming to life again. It seriously felt like being reborn, especially with the introduction of your radically altered anatomy!

After SP Removal.JPG

Everything felt new and fresh and I was soooo grateful for the freedom and mobility that has come with each new step towards full health. haha. It’s like that scene in Forest Gump when the bullies were chasing him down the dirt road and Jenny yells: “Run, Forest, RUN!!” And as he does he starts to bust out of the leg braces that he’s been wearing forever to help straighten his back. Annnd, life is just never quite the same again.

FOREARM: My arm is doing well, and looking super healthy:

Top Side @ 6 Weeks.JPG

At this point the graft is 99% healed and has been for a while. I’m well past any fears with it “not taking” which can be worries early on with patches looking odd and all sorts of colors going on.

Underside @ 6 Weeks.JPG

There are too teeny tiny scabs still present, both existing along incision lines. One where the two grafts are sewn together:

Graft Merge @ 6 Weeks.JPG

And the other along the edge of one of the incisions that meets the “bridge”. If I am too rough with massaging it with lotion they will open a bit and bleed the slightest bit. You might not even be able to see them in the photos because they are so tiny…

Bridge @ 6 Weeks.JPG

I continue to have some mild to moderate swelling in my hand. The amount of swelling really fluctuates depending on how much I’m using my hand and what I’m doing with it. The more physically demanding, the more edema.

Hand @ 6 Weeks.JPG

Funnily enough these two hand pictures were taken just moments from one another. Just an example of how deceiving photos can be. You don’t really see how swollen my hand is without the comparison to my non-donor hand, and the different angle helps too:

Hand Comparison @ 6 Weeks.JPG

I also continue to have some moderate swelling along the tattoo/incision line towards my elbow. But otherwise, the “leash” incision line has flattened out really well. Initially there were some weird puckers going on and they’ve completely smoothed out without a whole ton of effort on my part, just minor occasional massage.

Leash @ 6 weeks.JPG

Finger strength is pretty good. It was measured at my OT appointment 1 week ago (3/10/16) and it’s almost 2/3 of my non-donor arm. I think my grip strength with my left hand was 70lbs and my right was 45lbs. So still strong, but indeed has a long way to go. Wrist flexion continues to be my biggest noticeable issue/hinderance with my donor arm. I’m hoping in another 6 weeks that I’ll have about 80% (or more) of my range of motion back. I’m currently going to OT 2x per week. I planned my surgery to happen at the beginning of the year so that once I hit my max out-of-pocket the rest of my care for the year would be free. So my OT appointments are totally free now. No co-pay and no co-insurance. I think I have 35 visits per year, so I’m utilizing all the “free” care that I can get. I could certainly rehab my arm myself, but since I have the time and the free care, there’s no reason not to take advantage of it, it’s part of why I planned things the way I did… I’m using Eucerin on my forearm 1 or 2 times a day (I applied it more frequently initially). I have my silicone sheet that I just got recently –> Cica Care Silicone Sheet and I’m planning on wearing that for at least 6+ hours at a time to really help continue to flatten the scars out and blend them in with the surrounding tissue. This silicone sheet is VERY comfortable!

Cica Care.JPG

There is also a much cheaper option of a silicone sleeve that you can find on Amazon for a fraction of the price. It was recommended by Olga, one of the hand therapists at CPMC and she said has been used by a lot of guys. Depending on your graft size, you might even be able to cut it in half and get TWO sleeves out of it. You can find it here –> Silipos Gel Tubing. I was also given a cheap compression “sleeve” at OT (the one that’s cut off a long wheel and then they cut a hole for your thumb):

Compression Sleeve.JPG

It’s ok. I’ve worn it a couple times. It’s long enough that it covers the area I’m experiencing edema along my tattoo at the beginning of the “leash” incision point. They do wear out after a week or so of use and you eventually need to replace it. The other issue is that it doesn’t provide full compression coverage in my hand where the majority of my edema is. So I’m overall not into it, since it doesn’t address my main need from a compression garment at this time.

My hand therapist also fitted me with a relatively cheap compression glove at my OT appointment and charged me $12 for it. You can buy them here.  –>  Isotoner Glove. I ended up being an extra small. You might want to just have your hand therapist measure you for one so you don’t order the wrong size. It seems as though I’m a medium in most other gauntlets that I had been looking at online, so I was surprised when I was an extra small for this one.

Isotoner Glove.JPG

Today she started me using thera-putty and charged me $7 for one container of the orange strength.

Putty.JPG  Putty.2.JPG

FYI, you can buy a set of 4 containers/”strengths” on Amazon for $9 with free shipping –> Therapy Putty. I’ve always been given putty for free at every other OT location, so I was surprised they charged me for the putty and the glove. I have even been given a silicone sheet for free which are much more pricey than putty and an isotoner glove.

I’ve been given lots of hand exercises to do, with and without putty. I’ll include photos of the exercise sheets. From my first appointment at 10 days post-op, till present:

IMG_2402.JPG

IMG_2404.JPG

OT @ 6 weeks.jpg

THIGH: My thigh continues to itch like CRAZY! I’m often tapping or slapping at it though my sweatpants to make it stop… it doesn’t. So lotioning is really the only thing that helps. I’m applying lotion and massaging it probably 5-8 times per day. The lotion feels good but the massage really helps to stop the itching for longer than just a quick “rub & run” application (*wink). When I’m massaging it I can really see how the tissue is healing. I’m better able to see which areas are going to fade sooner than others and the general look of the scar is less severe after spending just 3 or 4 minutes doing this. I’m still experiencing drastic changes in the scar color depending on what I’m doing and what my body temperature is. If I’m colder or well vascularized it’s still turning a dark purple color:

Purple Thigh.JPG

If I sit down and rub my thigh for a minute it turns this pink color again and the purple fades away. This is just my personal experience with new scars – it will eventually stop.

Pink Thigh.JPG

PHALLUS/PEEING: Man, I feel like I am like an 8 year old boy. I am sooooooo grateful to have a penis and be able to pee from it. That function alone has totally transformed how I feel IN and ABOUT my body. When I stand in front of the mirror and look at my shape I am still just utterly amazed. Standing sideways looking at my profile and seeing my penis jutting down and slightly out is just so amazing. Even the color changes when I stand up – it flushes and turns a shade of pink, especially in the glans!!! I wasn’t expecting that and I view it as a total bonus for the time being, even though I’m planning on having veins tattooed and adding a more natural or flushed genital skin tone at some point. I honestly still can’t believe it, there are so many feelings I am still processing about all of this – mostly gratitude and joy. At times it’s just so overwhelming and I can’t fathom the reality that I am finally a man with a penis that I can relate to, and that I feel whole. I feel more whole than I ever dreamed was possible with this process. I’m not sure if this statement will convey what I mean for it to, and I hope that it doesn’t come across as offensive, because I certainly don’t mean it to. But I don’t feel like I have a phalloplasty – I just have a penis. And I’d imagine that’s probably a really common experience among the men that have this surgery. From the moment I woke up from surgery, I immediately felt it was mine, but when I had my glans done 15 days later, I deeply related to my phallus as the intrinsic piece of my body that I had been mourning for 31 years. The flesh, the warmth, the hang, the jiggle, the sensation of it in my hand as it fills up like a hose and thickens when I pee, and having something to shake off after I’m done. I’m sure these things sound ridiculous and silly to to people that haven’t lived with a missing body part that’s integral to so many different daily bodily functions, as well as being so intimately woven into their gender identity. But these seemingly “small” things have radically transformed my life in ways I don’t know that I’ll ever “get used to” or have the capacity to take for granted. When you’re life’s biggest need and deepest wish convene and MANIFEST, new ground is broken and what lies beyond is completely unknown territory. I feel like a massive mental landscape has been swept clear for me to focus on other crucial areas of development, growth, and pursuits that I was incapable of fully accessing till now. I still have lots of healing and stage 2 (erectile and testicular implants) to take care of, but the majority of the emotional shift for me with this surgery has already occurred and truly exceeded my expectations.

GLANSPLASTY: I am now 4 weeks out from this procedure and my glans is healing SUPERBLY! I haven’t had any issues with it since the bleeding drama I had while in SF. Once that was stopped using a 10 min pressure hold by Chen at CPMC, there have been zero issues. I was applying a layer of bacitracin to it 2-3 times per day for like 2+ weeks and then stopped about 10 days ago. There are still visible sutures present at the glans. I don’t pick at or try to remove them. I just let them do their thing. If they clearly appear to be unattached and dangling, then I will give a gentle tug or trim it. But only if it’s long or likely to snag on something.

GLANSPLASTY INCISION: This incision is of course also 4 weeks old, as it was the location where the graft was harvested to use on my phallus for the glansplasty procedure. The incision line looks beautiful. It’s thin, and very flat. I can still feel a few sutures present. Again, not messing with them. I’m happy to let them hang out till they’re ready to let go.

Glansplasty @ 4 Weeks.JPG

You can also sort of see the SP scar hidden in a nest of pubic hair. The scar has an interesting shape to it. It’s fully closed, and has been since within 24-hours of the catheter being removed (10 days ago). However, I feel like the pubic skin while I had the catheter, was being pulled down by the weight of my phallus more so than it was when they initially placed the catheter. At the time of placement, my phallus hadn’t yet been created and so I don’t think there was any tug happening to pull the skin down, I was also in a supine position. But after 4.5 weeks of having it in and the skin being pulled down a bit by the weight of my penis while I sit or walk, I think it contributed to a bit of a dimple. Here’s a closer look at it:

SP Scar @ 6 weeks.JPG

When you have an SP in the body starts to create a tunnel of skin that heals around the tubing. Once the tube is removed and the hole closes up, but the outer tunnel/scar tissue still remain. So when I press/rub on the scar I can feel where the tunnel used to be. I haven’t done any massaging of this scar yet, but I think with a little regular effort working at the adhesion, I can likely resolve the minor dimple.

NERVE HOOKUP INCISION: I’m fairly confident that all the sutures have finally dissolved/fallen out along this incision. I have done ZERO massage or moisturizing of this area – I probably should as it would likely help to lighten the scar. The nice thing about it though is that it largely blends in with my natural hip/groin crease.

Hookup @ 6 weeks.jpg

SENSATION: I still only have partial sensation in my scrotum. The far right side (opposite of the nerve hook up) is highly sensate (both tactile and erotic) but the rest is still numb. From what I understand this is not unusual and sensation could take many weeks or months to return. In terms of the phallus, I have both tactile and erotic sensation in some spots on my mons pubis around the connection point of the phallus. I was not expecting this, this is new. It’s a radiating sensation that feels like it’s coming from my pre-surgery penis – it’s interesting. Also, when I tug on my phallus or when I walk around with no underwear on, press my hips up against a counter that I’m leaning against, or grind into my bed while I’m laying on my stomach, I feel erotic sensations coming from the base where the little guy is buried. I started having orgams at day 34, just shy of 5 weeks. Having the ability to both pee from my penis, and orgasm is a total relief. Knowing that I can already orgasm while having zero sensation in my shaft, and that things are only going to get exponentially BETTER… well, it’s a beautiful life. I’m really looking forward to the nerve hookup growing in, but I am surprisingly not desperate for it. It just feels like an exciting bonus that I’m going to slowly start to experience – an unfolding of sorts. The painfully long wait just for my penis to be here and to gain the ability to stand to pee made me all the more grateful for it. I anticipate a similar experience in that over the next 2.5 years while full sensation grows in, in equal parts will grow my gratitude for that gift of that sensation, having had to wait for it as well.

VAGINECTOMY: I am continuing to deal with a pretty minor hole that opened up along my vaginectomy incision line. This experience is all too common and usually rectifies itself – so I’m not too worried. In the meantime it’s mildly annoying because it is leaking a very tiny amount of fluid (far less than it was initially) but it’s also tender and sore if I sit completely upright and put pressure on it. I keep it clean and dry and do a visual check of it almost everyday with a mirror. There looks to be no sign of infection, no puss, no red irritated skin around the small opening. However, to be on the safe side I did reach out to my local provider who performed my hysto exactly 4 years ago. She doesn’t personally do vaginectomies so she referred me to a provider that does. So I’m going to call on Monday and see if I can get in to have him take a peek at the wound and possibly swab it just to make doubly sure that there is no infection going on. It’s always good to play it safe. While I do feel somewhat self conscious of that area seeing as there is currently a form of small hole going on, I feel safe knowing that the provider who did my hysto and performs them on tons of transmen, gave me the referral. I also received a call from Crane’s office today and one of the nurses was checking in on me. I updated her about this issue and she reassured me that this is super common and eventually it WILL close up, but that it wouldn’t hurt to get it looked at by a professional. Hopefully by the next time I make another update it will have closed up/filled in. But I know it’s not uncommon for it to take many months at times. I can’t complain, this is a very minor thing and everything else has gone so well.

STAGE TWO (IMPLANTS): I’m currently aiming for stage 2 with Chen in San Francisco. Crane said I could have that done as early as October, which is when I’m hoping to be scheduled. I’m waiting on a call back from their scheduler to set an exact date. The plan right now is to get the inflatable, and one testicular implant, since the implant will utilize one nut for the placement of the bulb to pump up the inflatable. I hope eventually they design the bulb on the pump to emulate the size and shape of the testicular implants that are available. It’d be really nice to have two testicular implants that are more closely symmetrical. I don’t think visually it will really be noticeable, but it would be nice to feel the symmetry as well. Until just recently with the “Zephyr Implant Line” up and coming there were no erectile prosthetic implants that had been designed specifically for the neo phallus, and the FTM one at that! The current pumps with their odd shaped bulb is designed to be implanted in the cis male scrotum, and the patient retains both of their testes (assuming they have two). So it was never meant to replace a missing one, as it should in our case… I’d be tempted to ask for two testicular implants as well as the pump and just have the bulb be a third entity, as it is in natal males that have an IPP (intrapenile prosthesis) or ED (erectile device). However, it’s my understanding that the European teams site that the most common reason for failure of the pump is typically related to tightness and lack of space in the scrotum. For that reason alone it wouldn’t be worth it to me to risk it. I think I will be getting the Coloplast inflatable and either a medium or large testicular implant (whichever fits).

Alright. That’s all I got for now. I’ll catch ya again probably around 8 weeks if I feel like there have been some changes that seem worthy of posting about in the next couple of weeks. Take care guys. Thanks for reading and of course, feel free to ask any questions or make requests.

Dr Loren Schecter (New York Presentation & Mini-Consult)

Loren Schecter PhotoI recently attended Dr Loren Schecter’s presentation in New York that was made possible by the non profit organization: CK Life. Being that I live in MA, this was a bit of a drive for me, but it felt worth it. Dr Loren Schecter’s name has come up more and more over the past few months and he was on my radar as being a surgeon whose waiting list is around 6 weeks. That alone was a huge driving force for needing to at least hear him speak and get a feel for if he would be an option that I was comfortable with. Although his presentation covered the gamut in terms of MTF and FTM procedures, because of the nature of this blog I am only going to be mentioning anything related to phalloplasty.

Dr Schecter was available for free mini-consults prior to his presentation. I actually attended with a buddy of mine and we are planning on scheduling our surgeries a couple days apart so we just did our consult together and that really allowed us to not miss any of the questions that we had. That, as well as making a list of questions (and continuing to add to it) WELL in advance is really key to utilizing your consult time in the most efficient way – I can’t stress this enough.

So let’s get right to it. First I will document the actual consultation and then give a rundown of his “powerpoint” presentation and share my overall impression and experience of meeting him…

Just like my Crane consult, this is not word-for-word what Dr Schecter said and I am in no way quoting him. The following is a recap to the best of my ability to share with you what I remember him saying:

Me: Tell me a bit about your background. Where did you learn to do phallo and how long have you been doing them?

Dr Schecter: I worked with the Serbia and Belgium team, I started doing phalloplasty back in the 90’s.

Me: How many have you done at this point?

Dr Schecter: About 25 or so.

Me: So you’re a plastic surgeon and a micro surgeon, is that correct?

Dr Schecter: Yes

Me: So you bring in a urologist to do the UL (urethral lengthening)?

Dr Schecter: Yes, we have a great urologist that we work with, and also a reconstructive urologist that we can bring in if we need to.

Me: What are your complication rates?

Dr Schecter: They are about 40%

Me: How are those rates effected by one’s choice to either have or not have a vaginectomy? How much higher are complication rates if you don’t do a vaginectomy?

Dr Schecter: You mean with urethral lengthening? Because we only do UL with vaginectomy. If you don’t want a vaginectomy then UL is not an option.

Me: Do you perform a VY scrotoplasty?

Dr Schecter: I don’t perform that exact scrotoplasty technique. What we do is very similar in that it brings the tissue forward and creates a hanging scrotum but we don’t call it VY.

Me: What is the positioning like for the arm flap for RFF? Is the urethra formed from the skin on the underside of the forearm?

Dr Schecter: I don’t have my templates with me right now but essentially the flap is harvested starting on the underside of the forearm along the pinky finger side of the arm (ulnar). That is the tissue used for the urethra, and the flap continues almost all the way around the arm. The skin along the arm where your thumb is (radial) will end up being the “top” of the shaft (ie the skin that would be most visible when looking down at your penis). The skin on the top of the arm would be wrapping around to the underside of the penis.

Me: Have you ever had any total phalloplasty flap failures?

Dr Schecter: No we haven’t. But sooner or later it could happen. I do all sorts of flap surgeries in my work that are not phallo-related and I have seen flap losses happen, but we’ve never had a phallo flap fail.

Me: Where is the incision line on the penis for the RFF phalloplasty placed?

Dr Schecter: It used to be on the top but now we place it on the underside. ALT incisions are on the top and the bottom.

Me: Do you ever do full thickness skin grafts to cover the flap site?

Dr Schecter: We sometimes have, but we’ve seen enough promising results from using a combination of Integra and a split thickness graft that we usually don’t do full thickness grafts. Because it becomes an issue of then where we get that skin from.

Me: I noticed that the hospital stay of 2 weeks post-op is longer than other surgeons are quoting – Can you speak to this?

Dr Schecter: 10-14 days. It varies person to person. We do a scope of the urethra before you leave and we also do the secondary surgery that places the split thickness skin graft on the donor site, because using the Integra requires a separate procedure a week after the phalloplasty.

Me: Do you anchor the penile prosthesis to bone or is it stitched in place?

Dr Schecter: We do a variety of methods. Sometime we anchor it to the bone other times it’s sutured in place.

Me: I’m worried about having a really skinny penis because of how lean I am, have you done phallos on guys my size and if so how were their results in terms of girth?

Dr Schecter: It’s actually beneficial if someone is lean because it makes the surgery much easier. Sometimes with people that are on the heavier side we are looking at needing to add grafts to be able to completely close the phallus. In terms of girth the penis still ends up being a reasonable size.

Me: When you de-glove the clitoris do you leave the erectile tissues?

Dr Schecter: Yes, we are only removing a very thin layer of skin.

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That was pretty much all the questions that I can remember asking in looking back at my notes. I didn’t write down my buddy’s questions but these were the bulk of them. As for the presentation itself, much of the information that was covered was not phallo specific, understandably. He covered most ALL of the procedures that he offers to women and men as well as took time to do some trans 101 and just talk about his practice in general. This makes sense because there was a very wide variety of people attending the presentation including some healthcare professionals. He did show a few pictures of RFF and ALT and I think he might have shown an MLD but I can’t recall. He did have a graph that layed out the pros and cons of each method give them ratings/stars in terms of what donors site offers the best sensation, girth, size, rigidity and so on. This was helpful to see, so if you consult with him you might ask to see this if you are still on the fence about which donor site is right for you. Also it’s worth mentioning, that if you are HIV+ or have an STI he is still able to operate. However, folks have to be on medication or have their conditions under control. If you have any open wounds at the time of your operation this would be a contraindication to surgery.

My overall impression of Schecter is a positive one. I know that public speaking can be awkward and that is not always the realm in which all folks exceed but he seemed well spoken and compassionate.

THE PROS (for me personally): His waiting list is a TINY fraction of what Crane’s is. You’re looking at MAYBE a couple months out from the time of your consult. He also refers people out to a local electrolysis technician that is familiar with his procedure and the phallo “template” that he uses and typically the hair along where the urethra will be can be removed in one session. Just to clarify, the outside of the penis would still grow hair if you currently have hair in that area already. This is strictly a strip of skin used for the urethra where the hair would be removed. Also, another HUGE PLUS is that because he is on staff at a hospital and not in a private practice it makes using insurance with him MUCH easier. Even if you have a state funded low-income type of insurance, as long as you get the go ahead from your insurer, reimbursing the hospital at a much lower rate is not going to be an issue in the same way that it is with someone like Crane who has a personal practice with a lot of overhead. I was told today by Katrina (Dr Crane’s nurse) that Medicare has offered as little as $1,100 for phallo, it’s truly laughable what Medicare and Medicaid are willing to pay out. So if you have this type of insurance and are looking to move forward with surgery sooner rather than later, Dr Schecter might be your guy!!!

The Cons (for me personally): I’m probably 90% positive that I don’t want to have a vaginectomy. It’s a procedure that I don’t feel like I NEED at this point even as someone who practically never engages in anything penetrative. I want the option of changing my mind on this procedure up to the last minute. There is a chance that in the next 10 or 11 months leading up to surgery that I might change my mind and decide: Sure, get it out while you’re down there. But I’m fairly certain that I won’t. This wouldn’t be an option with Schecter. So really for that reason alone, I have to admit, my brain kinda shut down in terms of considering him as an option for myself… The other fairly large factor in my decision process even if not having V-nectomy was an option with him, was that a complication rate of 40% felt a bit high for me… I did however think his work looked solid, however, I would personally want a much more defined glansoplasty. This could totally be a personal choice that the good folks in the photos chose for themselves, so it’s hard to know if that’s just his technique or a personal decision. Also, his cut seems to be one that is a very clean even circle around the tip of the phallus where I would prefer a more comprehensive cut that looks different towards the frenulum than it does on the top side of the head of the penis – rather than being uniform all the way around. Again, these are my desires for glansoplasty and not everyone’s, he very well might offer this if asked. And let’s be honest, although glansoplasty has the potential to add a lot of aesthetic appeal to a phalloplasty, it’s fairly minor in terms of the “whole package” and doesn’t impact functionality at all. So even if you don’t like his glansoplasty technique it would be easy enough to have someone else do it or ask if he would be willing to perform a different technique that suits you better.

Lastly: I won’t put this in the cons list but I will add it as just general “room for growth” after having seen his presentation and spoken with him. It’s very clear to me that Dr Schecter is a compassionate man and is interested in helping folks like us mend these delicate and sensitive parts of our bodies. However, I did notice that some of the language he uses could be off-putting to some. I noticed that he referred to a completed meta and talked about it using the word “clitoris” where I feel like he really should have been saying “penis”, “phallus” or even “glans”! Although I recognize that not all people that have top surgery are male identified, and not everyone that is *trans male is “cock identified”, I’m willing to bet that far more ARE than ARE NOT if they are seeking a reconstructive PENIS surgery… I’m sure that someone mentioning this to him would be all that it would take to help shift the way he approaches speaking about these body parts. I just know that if I was post-op meta and my surgeon was calling my penis a “clitoris” I would be devastated! There were some other things he sited during his presentation like that far more men than women seek these surgeries and although I think I knew what he was trying to say (more transwomen than transmen) I think I might have either said that or: “more people assigned male at birth than females”. Again, these are REALLY subtle nuances to most people, but I think if he sees himself expanding and offering care to more trans folks, he would benefit from a little more understanding with how we speak about our bodies and just the general language that tends to me more respectful and understanding of the ways we relate to our bodies. All that being said, I freely admit to being a virgo and a bit overly critical at times. So take this as you will – He’s a great guy with good intentions.

I think Dr Schecter is certainly a great option for some folks. Choosing a surgeon is a REALLY…PERSONAL…DECISION… and you have to go on your gut instinct for who will be most able to meet those very personal needs. Sometimes this process is like shopping for jeans – they usually look great on the mannequin, but upon further inspection and a more personalized quick trip to to the changing room you immediately feel any areas of discomfort and need for other options. OR you run to the check out line eager to pay and bring home your new favorite jeans. The latter was my experience with Crane. The jeans looked great on the mannequin, the fitting room experience was shockingly wonderful, and now I’m just in that dreaded long line with 50 people ahead of me hoping that my credit card won’t be declined… So, at this point, I’m still moving forward with using Dr Crane as my surgeon. However, if for some reason my plans A, B and C with health insurance don’t allow for me to have him do my phallo, I might give Schecter another look.

Phalloplasty Consult w/ Dr Curtis Crane

Dr Curtis CraneAt 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.

My Vision For This Website

topics

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Insurance Coverage

Hair Removal (laser & electrolysis)

Health & Fitness

Phalloplasty 101

Surgical Options w/ Phalloplasty

Erectile Devices/Implants

Personal Deciding Factors for Procedures

Helpful Links to Related Resources

General Tips and Suggestions

Lists of Questions For Surgeon Consults

Lists of Questions For You to Consider

Travel Planning

Regular Updates Throughout Surgery Stages