2 Weeks Post-Op Stage 2 (Semi-Rigid Rod & Testicular Implants)

My stage 2 surgery was on October 11th, 2016 with Dr Chen at the Greenbrae Surgery Center in San Francisco. The surgery itself went fine and there were no major issues.

TESTICULAR IMPLANTS: The right side of my scrotum ended up being a tad bit smaller than my left side and so Dr Chen had to shave down silicone-carvings-1 that testicular implant so that it would fit into the sack. Had he not done this it’s likely I would have had issues with erosion if he tried to force the full-sized medium implant in. The nice thing about the Silicone Carving implants that Crane/Chen use is that they allow the surgeon to modify and shave it down to the exact size of the tissue that they are working with. That way you aren’t limited to just small, medium, or large which is the case with any of the gel or saline filled implants – rather, you can get the perfect sized ones for your body with the carvings if the space you can accommodate falls somewhere between the factory issued sm/md/lg. The other thing worth mentioning that Dr Chen noticed while placing the right implant was that the skin was fairly “thin” meaning I could be at a higher risk for erosion on this side which was a contributing factor in his decision to shave the implant down a bit to take some of the tension off the already thin skin and smaller space. I appreciate his conservative approach and efforts to not make a risky decision even though I expressed how much I really wanted the largest implants possible and to have two symmetrical testicles. These factors weighed heavily into my decision making process when choosing an erectile implant type, but I far and away prefer having slightly uneven testicles than risking erosion and ending up with only one testicle, or even none! Ultimately though, my hope is that over time the tissue will stretch with the weight of the implant, gravity,  and by manually stretching it myself. Down the road, be that many months or years from now I think it’s reasonable to assume I’d be able to fit a full-sized medium implant in the right side as a small revision add-on while I’m having an erectile implant replacement/switch.

ERECTILE DEVICE – SEMI RIGID/MALLEABLE ROD: The model of erectile device that I had placed is called the AMS Spectra, one rod, not two. Prior to1-ams-spectra_300 surgery we had discussed doubling up on the Gortex sheath that he wraps the rod in, in order to further aid in bulking up the penis. Upon getting inside though it became clear that I didn’t have enough space to accommodate a second layer of the wrapping. So my surgery was similar to the technique he has always used when placing the rod. He also told me that he was really happy with the positioning that he was able to get and the angle at which the rod was mounted.
Everyone’s pelvic bones are angled just a bit differently, so they don’t know exactly how things will end up being mounted until they get inside and look. He said that in the OR he was able to fully bring my penis straight up against my stomach and that I had a great range of motion. However, since I woke up from surgery I have not been able to bring my penis up higher than a right angle from my body. I can make it stick straight out but I can’t

dacron
Image on right is similar to the Gortex (Dacron) used to wrap the rod

can’t bring it fully up against my belly. In the O.R. there is no swelling so it could just be that all the edema is what’s preventing me from getting the same full range of motion. However, I’m also noticing a strong tugging/tension on the underside scar (from stage one) that the runs the length from tip to base on the penis. The lower portion of the scar when I try to bring my penis upwards feels like the point of tension that is making me feel like I shouldn’t raise my penis any further. It’s also worth noting that this portion of the scar is hypertrophic (thick and raised, but clear/white in color) so it’s my intuition that this scar is what’s causing the issue and that the reason he was able to bring my penis all the way up in the OR, was because my pain from over-stretching that scar didn’t stop him while I was under anesthesia. However, Dr Chen said upon physically assessing things at my post-op appointment, that he believed it was the swelling at the pubic mound where the incision to insert the prosthesis was made (photos below) that is likely causing the current lack of mobility/tension. He told me to continue to gently but firmly test my limits for how high I am able to angle it and that he thought I should see improvement as the swelling subsides. I’m trying to stay positive while also being realistic. I truly believe it’s the underside scar that’s holding it down and I’m not sure if or how this problem can ultimately be remedied if that is the case. I don’t think it’s an issue that would inhibit sex, but it could potentially limit sexual positions and definitely already does limit positioning options in my underwear since wearing it down is the only angle it is comfortable in, pointing up is not an option. Time will tell if this ends up improving or presenting as a problem that needs correcting. One option I am beginning to mull over is potentially getting Kenalog injections along the scar which might help flatten it, but I’m not sure that it would impact it’s flexibility/stretchability at all, which I believe to be the true issue. Pre-implants I had been sleeping with my penis in an upright position to stretch/flatten this scar because I had noticed that it was thicker and almost seemed to bunch a bit from wearing my penis down all day since it’s right in the underside crease. I will continue to update about this issue as I gather more information about corrective options or as things hopefully positively progress on their own!

ERECTILE IMPLANT INCISION: I’ll be curious to see how the pubic scar on my mons from erectile-implant-incisionthe erectile implant heals as it’s about 1.5 inches below the SP scar, about 1.5 inches long and located less than one inch above the connection point/scar of where my penis is attached to my mons. I’ve had quite a bit of swelling at this site over the last two weeks. If I’m up and being more mobile (ie: cooking, driving, walking) I notice that the swelling here increases. I’ve been addressing this by icing 20 min on, 20 min off and that has helped to decrease the swelling.

SUPRA PUBIC CATHETER SCAR REVISION: This was a super minor revision and unrelated to the erectile or testicular implants. At stage one in February I chose to keep my SP catheter in for an additional 2 weeks because I had a bit of a urine leak coming from my scrotum. I chose to do this to allow further healing of the UL without the added pressure of urine constantly flowing through the healing fistula every time I peed. In doing so, I added to the amount of scar tissue that builds up around the SP tube from belly to bladder, since the longer you leave an SP in, the more scar tissue that grows around it. What formed was a thick stalk of scar tissue inside my body that ended up healing with some adhesion so that the skin at the point of the external scar does not float and move normally over the structures below it – it remains stuck . I’ve tried manually breaking up this scar tissue with massage,  but the stalk of scar tissue under the skin is far too thick. So I asked Dr Chen to break the adhesion since he was going to be “in the area”. sp-scar-revisionThe first 1 or 2 days post-op I noticed that the skin was free-floating and mobile. But after a few days had passed I tried to move the skin and it had adhered to the stalk of scar tissue below it again. I had a conversation with Dr Chen prior to surgery about the SP adhesion and I asked whether or not he would be removing the “stalk” of scar tissue as well, to which he said: no, he wasn’t going to chase the stalk because that increased the risk of damaging surrounding structures, and he wanted to be as minimally invasive as possible. We discussed this re-adhesion at my post-op appointment and he was disappointed to find out it had re-adhered. He said it was good information to know though, so that if he ever did this procedure for someone in the future he would advise them to constantly be massaging the scar early on post-op to discourage any re-adhesion of the tissues. I will probably have this adhesion broken again at some point in the future but I would only do so if combining it with other procedures. Again, it’s not a big enough issue that it causes pain or distress. I would just prefer the skin float rather than stick as it does make the scar a bit more noticeable. But still, really minor issue and not something that would equate to even being a minor complication, rather just a common factor in healing from any surgery that produces a scar -adhesion is always a possibility.

PERINEAL DIVOT REVISION: My body took a long time to heal from the revision I had back in June to remove some granulation tissue that had formed at the point of vaginectomy closure at stage one. I had a fistula (not urinary related, just a hole or opening) that had a lot of difficulty healing. When I had the revision in June it opened back up and again had trouble healing. When I finally used an antiseptic powder on this site, it miraculously closed. However, it was open for so long that it did leave me with a small divot once it finally healed. This time around this area has healed well and when he did the revision there was no granulation tissue at the site which is great! I haven’t gotten too up close and personal in that area because I’m still pretty limited in how mobile/flexible I can be. Squatting is quite painful and I try no to do anything that increases pain, as those were a big part of my post-op instructions. If it hurts, STOP – or DON’T DO IT! I have used the Columbia Antiseptic Powder a few times just to make sure that area is healing over well, but I haven’t felt or noticed any issues with it. However, it does feel like there is minor tactile difference/dip between the perineal raphe and where it connects to this revised area which is about an inch from the anus. It’s subtle but it’s there. So I’m not quite sure yet if the revision actually improved the divot or not. I thought I would include a diagram of the male perineal area which labels all the different structures as a reference point. I thought folks might find comfort in knowing that many natal males have a visible raphe/ridge that runs from the underside tip of their penis to the anus. Their bodies closed this gap in utero, whereas transmen who have phallo and opt-in for a vaginectomy and achieve this closure via an incision line really aren’t all that different from the natal male anatomy in this sense.

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This is not a picture of my anatomy, this is an example of a natal male.

 

PEEING W/ THE ROD: Initially it was a bit harder to urinate the a couple of days following surgeryholding-a as I’m sure I had a good deal more swelling than I do now. I was also in SOOO much pain when I stood up that once I got to the bathroom I needed to sit down to relieve pain before I was able to relax enough to pee. Sitting to pee is more difficult for me and I think it’s something about the changed angle of the neourethra with the natal urethra ever since stage one that has made it a bit harder to pee in that position. I’ve noticed it takes longer to empty my bladder and my stream is weaker when my body is bent at that angle. The differences I’ve noticed with urinating since the rod has gone in is that I prefer to hold my penis differently now. I instead of holding it in the “A” position (pre-implants) I now hold it in the “B” position. The reason for this, is the rod is now filling up my penis as much as is safely possible without minimizing the needed space for the urethra to expand and fill with urine. If I hold it like photo “A” gravity is angling the rod down and adding pressure holding-bagainst the urethra where my hand wraps around the underside and creates further pressure. I can still pee that way if I really wanted to but I can feel the urethra being somewhat compressed and it’s just more comfortable to give it the full amount of space by holding the sides or top half of my penis so that the underside, where the urethra runs is unobstructed. I meant to mention this earlier, but if the last sentence didn’t explain it and you’re still wondering, the rod is placed on the topside of the urethra… This dick-handling adjustment hasn’t been all that big of a deal. Grip “B” is not quite as instinctual or natural as “A”, but it’s a small price to pay for being the proud owner of a hard dick. Also, if I really wanted, I can easily pee without holding my penis at all since the rod really keeps it at whatever angle I put it in. But it just feels more natural to hold him while I’m peeing. And since I’m not really holding him UP exactly when I’m peeing, I’m really kind of just mostly using my thumb to guide him in the direction I’m aiming, if that makes sense.

BENDING THE ROD/STIFFNESS: The rod is actually a fair amount stiffer than I had anticipated. I messed around with the model that was in the office, but I’m sure that one has seen plenty of handling and was likely much looser for that reason. I do think that even in the 2 weeks since I’ve had it, it’s already started to loosen a bit and I’m quite happy about that. There was a palpable clicking sensation when pointing my penis in different angles. I could also hear a very soft clicking noise as the “joints” flexed into different positions, and I can’t say I found that aspect all that sexy. It made me wonder what that sensation might feel for my partner when I was inside them. I’ll have to get back to you on that one as it continues to loosen up. The good news is that I’ve talked with some guys that have had the rod in for months or even years longer than me and they reported that is did indeed go away! Otherwise the rod is easily bent and positioned with one hand. I can move it up to a right angle and even a bit higher. If I am laying down and I point it to a right angle my penis will stay pretty much at whatever angle I put it in. If I am standing it will want to lower a bit, but generally will stay close to the angle that I put it in when I take my hand away.

(GIRTH) SIZE INCREASE: At this point and there is likely still a bit of swelling along the shaft but not much, but I’ve gained close to 3/4 of an inch in girth. This might not seem like a whole lot, but slight increases in girth are much more drastic than slight increases in length, in my opinion anyway. I feel much more comfortable with my girth now. Ideally I would have landed squarely on the 5 inch mark for a nice beefy thickness, but the 4.5ish range feels like a reasonable size to me as well. I can comfortably live with that and feel satisfied.

GUESSTIMATIONS ON EASE OF PENETRATION: I honestly can’t speak from experience about this for obvious reasons. Being only 2 weeks out I’m nowhere near being able to use my guy for play yet. However, I will say that going into this, I anticipated having far less rigidity than I do. Obviously I was getting an erectile implant for the purposes of topping. But a VERY close second on that list was choosing an option that enhanced my current package and really beefed things up. From obsessively reading phallo listservs over the past decade, participating in groups, and talking with numerous guys who have had different models of the rod, I’ve heard more than a couple guys say they wished their erections were firmer and heard some guys have issues with buckling, or the tip of the head drooping over the end of the rod which was possibly placed very conservatively far back behind the glans, etc. But I must say, I’m impressed. My rod goes all the way to within one cm from the tip of my penis, so I don’t anticipate any issues with the head not being firm enough and causing issues with initial penetration. There is zero droop at the tip of my penis. The rod itself bends easily, yet gentle exploration thus far seems to look like it will be plenty firm enough for sex, both vaginal and anal. Again, I’ll have to give factual, experienced-based updates on this at a later time… for the good of science of course!

SENSATION/ORGASM: This is a big one and I almost left it out. Since the rod was placed I completely lost all sensation in my penis. ALL of it. I had the most sensation at the tip which was incredibly sensitive and a few large spots around the shaft where sensation was coming in. Dr Chen assured me that it really should come back and that it’s fairly common but that it could take a few months up to a year to come back and that it’s likely that the nerves are just in shock. I’ll be totally honest and admit that I’m pretty scared. This fear provoked me into making sure I still retained the ability to orgasm even in spite of not having any shaft sensation. I’m happy to report that all is ok. Although I don’t recommend it, since you’re risking detaching the erectile device, we do what we have to do to manage and get through these really difficult surgeries where there are of course no guarantees and a level of uncertainty even though most guys will make out ok in the big picture. I personally don’t know any men that are not able to orgasm. I know guys that don’t have much or any shaft sensation but orgasm is still possible. I won’t get too much into the mechanics of all that and exactly how it’s possible, but I’ll say that the base where my penis was fixed to my pubic mound, is HIGHLY sensate and erogenous. Actually quite a bit more so now with the introduction of the testicular implants and i believe also the placement of the rod had something to do with it. I can actually “reach” (stimulate) my original smaller buried penis easier than I could pre-implants. Hopefully the nerves are just stunned though and they’ll wake up soon. I’ve spoken with some other rod-guys and they had a similar experience. So chances are everything is fine. I also noticed post fat grafting that my sensation decreased a fair amount for a while. It makes sense if you think about it because they are jamming things down into the penis where the nerves are growing for both the fat grafting and for any erectile device, rod or inflatable.

THE BATTLE OF THE BULGE!: Ok, so I’m pretty IMPRESSED! Again, there is certainly some getting used to this aspect of having a firm penis 100% of the time and never being flaccid. BUT, I must say, I really am enjoying it so far! I feel like it’s definitely had the impact on my self confidence that I had anticipated would result immediately following stage one. Had my forearm contained a more dense layer of subcutaneous fat, I think it’s likely that would have been my experience immediately following stage one. But this stage feels really fulfilling for me because it’s finally “scratched that itch” that I’ve been desperately waiting for since stage one and just never felt like I landed on. I experienced some pretty heavy depression in February after my first surgery, I believe in large part because this basic need I had just didn’t feel met. But now I really enjoy how effortlessly I fill out my underwear and I love reaching down and feeling my full package. I can’t speak from the experience of having had the pump (since I haven’t) and being able to compare this to that. But I do believe this experience is a better fit for me, at least at this point in my life given the current erectile device options that are on the market as well as current options for insanely expensive, “permanent” (lasting up to 2 yrs) fillers to add fullness and bulk to the penis. The pump is absolutely amazing in that it allows for the more natural experience of a flaccid AND and erect penis and all the stages in between of becoming erect and filling up. I do hope I get to be able to experience that some day as well. Clearly that’s the more “natural” option for many, if not most guys that are seeking an erectile device. But with my circumstances, I really do like that even though I’ve ended up with a more modest sized penis both in length and in girth, that I appear to be a show-er now, even if there’s no growing that will be happening later on, no passersby actually know that. That’s been really exciting for me – a definite confidence booster. Here are some quick photos I snapped just to show what my guy looks like in undies. The bulge is definitely MORE noticeable with just underwear – and much LESS dramatic/obvious with shorts or sweats on over the top. Also, keep in mind that I do have some swelling still going on (mostly scrotal)… Once I get back home and have more clothing options to play with I’ll probably snap some better photos in a few different kinds of underwear and types of pants, shorts, sweats etc. and model those for you.

 

SLEEPING: It’s still very EARLY DAYS and so I’m sleeping on my back to not cause any pressure on the pubic connection point. This is pretty miserable because I’m predominantly a belly sleeper, and an occasional but much less frequent side-sleeper. I’ve done a bit of side-napping using two very fluffy pillows propping my legs apart and then propping my penis up a bit so it’s not dangling at a drastic sideways angle. But I’m really paranoid that I’m going to fall asleep and then try to roll the rest of the way over onto my belly. It’s hard to know for sure yet, but I think I should be able to comfortably and safely belly sleep in another 4-6 weeks. I am doubtful that I’ll be able to do as many belly facing yoga poses as I was able to in the past though. I can indeed see this device potentially limiting me in that sense when it comes to lying on hard or even firm flat surfaces. Being a really lean guy means that I don’t have that extra belly or thigh fat to buffer the rod that’s sticking out when lying on my stomach. Hopefully I’m wrong about this though. If it ends up restricting my mobility enough it could be the deciding factor in eventually switching to an inflatable.

THE SHWING!!!: Alright, so I am noticing a bit more movement and jiggling while I walk as the days progress. I’m sure the decreased swelling and the loosening of the joints in the rod are probably equally responsible for that. Things of course don’t flop around nearly as much as they did pre-stage two, and it’s undoubtedly a big adjustment. I enjoyed my floppy dick, but not all the time, and not all that much. I didn’t like how it fell between my legs when I was sitting or driving – I felt like it got lost down there. Of course, the lack of testicles I’m sure played a large part in that too. But overall, I wasn’t all that happy with the size of my package. I had always imagined myself having a lot more going on, even though I’m really not a size queen. Anyway, things seem like they’re loosening up a bit. I notice that it is more likely to swing left to right a bit than it is to go in any other direction when I’m walking. There isn’t much downward motion/bounce since the shaft sits firmly against my scrotum and I kind of curve him around my nuts. I wouldn’t mind a bit more of a SHWING when I walk, but I may get that over time as swelling continues to go down, and the device continues to loosen up a bit with some *ahem*, “use”.

WRAP IT UP: I think that mostly covers things for now. My next post: which is already in draft, will be an explanation of Pump vs. Rod – How I Decided. I’ve been getting that question at least daily and I figured it’d be easier to have a post to direct people too with the long-winded reasons rather than typing the cliff-notes version over and over… As always, if you have any questions please feel free to ask or make requests for specific topics to be covered. I will update on all of these topics again at the 1 month mark. I can’t promise that it will be posted exactly one month post-op to the day, but I am still aiming to get all the correct content in for the listed timelines even if they are days or weeks late to go live. Thanks for reading!

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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.

*           *           *           *           *

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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7 Weeks Post-op, & Stage 2 Update

Heys folks. Not really a ton to update about this week, in terms of things looking differently, so no pictures. I do have the last remaining stitches from my glansplasty finally flaking off, which is nice. My arm pretty much looks the same as last week as do the rest of my scars. I’m still having a bit of trouble with the hole along my v-nectomy and decided to have a “local” (90 min away) specialist look at it, just to make sure there is no infection and to have someone actually following me, since I’m really not seeing anyone right now. So this afternoon I’m driving to Boston to meet with a urogynecologist… ugh… It’s for the best though. After the appointment I plan to send an email to Crane and follow up with him as well to cross check any instructions I’m giving to make sure it’s safe and he concurs. The main thing I want to confirm is that there is no infection, which it doesn’t look like there is. Last weekend I was running a fever though and feeling really ill, so, another reason to be checking in with someone about it all. The other thing I’m not sure if I should be doing is packing the hole. I know a lot of guys have been instructed to pack their wounds and Crane never told me to do that when I had my last post-op appointment with him. Since I left CA, the hole did open a bit further into an area just below, where the incision line looked weak, so I was expecting that to happen. It’s still relatively small. I don’t think I could fit the tip of my pinky in their. So hopefully after meeting with him and emailing Crane I’ll have some further direction on how to move forward. I think it’s just going to take time, as my understanding with wounds that are holes is that they need to heal/fill in from the inside.

I’m generally feeling really well! I had initially taken 3 months off work and I’m now considering going back a month early! I feel strong. To be honest I probably could have gone back at 6 weeks, it would have been tough, and I’m glad I’ve had the extra time to take it easy and continue to heal, but I just don’t know that I need an entire extra month. Depending on how today goes, I might contact my employer and let them know. The hole along the v-nectomy is sore and annoying, but it’s really not bad enough to keep me from working. My arm is still stiff and not 100% but I think working will just be further exercise and rehab for it getting back to normal faster.

Lastly, I’ve scheduled my date for stage 2!!! I currently have a date to get the inflatable pump and one testicular implant on October 11th, 2016 with Chen! At some point I’m going to have a phone “consult” with him about some remaining questions that I have surrounding the surgery as well as the best practices they use. So I won’t get into all of that right now, but I will eventually do a detailed posting with the info I find out. I’ll check in again at 8 weeks.

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.