Download 0910 Fundamentals of Gender Reassignment Kuzon

Fundamentals of Gender
Reassignment
William M. Kuzon, Jr., MD, PhD
Reed O. Dingman Professor of Surgery
Section Head, Plastic Surgery
University of Michigan
Gender Identity Disorder
(DSM-IV 302.85)
Incidence
– Not certain but
estimate:
– 1:12,000 males –
25,000 in US
– 1:30,000 females –
10,000 in US
Etiology
–
–
–
Biological
Social Learning
Cognitive
Development
“A strong and persistent identification
with the opposite gender.”
History of Treatment of GID
Dr. Harry Benjamin - endocrinologist
HBIGDA – www.hbigda.org
Now WPATH – World Professional Association for
Trangender Health – www.wpath.org
“Standards of Care”
John Hopkins Program 1970’s
Free University of Amsterdam
Resurgence of sex reassignment surgery in North
America – accelerating public awareness
Major Centers in Europe, North America, Asia
UM CGSP
Program coordinator tracks
all patients
EMPHASIS ON
MULTIDICIPLINARY CARE
–
–
–
–
–
Therapist
Primary care
Specialty care
Second opinion
Surgical Referrals
Plastic Surgeon
Urologist
Gynecologist
– Other providers (electrolysis,
speech therapy)
Mental Health Team
– Readiness for surgery
Core Team
– Surgical Transition
WPATH Standards of Care
Designed to protect
both patient and
provider
A “roadmap” for sex
reassignment
– Psychotherapy
– Hormonal Therapy
– Real Life Test
– Verification of readiness
for SRS by mental
health professionals
Male-to-Female (MTF)
? Majority of GID patients
Range of Surgical Options
– Facial Feminization
– Thyroid Cartilage Reduction
– Breast Augmentation
– SRS
Male-to-Female (MTF)
Facial Feminization
– Hairline correction
– Forehead
recontouring
– Brow lift
– Rhinoplasty
– Cheek implants
– Lip lift
– Lip filling
– Chin recontouring
– Jaw recontouring
Facial Feminization
Thyroid Cartilage Reduction
MTF – Breast Surgery
“Top” surgery
Sub-muscular augmentation
350 ml saline implant
MTF SRS (“Bottom” surgery)
Penile Inversion Vaginoplasty
One stage operation
“Like” becomes “Like”
Reliable and predictable
Good functional and aesthetic results
Acceptable complication rate
– Tissue loss
– Rectal fistua
MTF – Penile Inversion Vaginoplasty
D/C hormones 3 weeks pre op
Mechanical Bowel Prep day prior
OR – 4-6 hours
–
–
–
–
Possible need for transfusion
Catheter
Vaginal packing
Drains
Removal of pack, catheter, and drains POD 4
Vaginal Rinses x 3 weeks
Restart hormone therapy when return to OR is r/o
Vaginal dilation when fully healed
PO f/u then annual exam
Prostate cancer in a transgender woman 41 years after initiation of feminization.
Miksad RA. Bubley G. Church P. Sanda M. Rofsky N. Kaplan I. Cooper A.
JAMA. 296(19):2316-7, 2006 Nov 15.
MTF – Penile Inversion Vaginoplasty
MTF – Penile Inversion Vaginoplasty
MTF – Penile Inversion Vaginoplasty
MTF – Penile Inversion Vaginoplasty
MTF – Penile Inversion Vaginoplasty
MTF – Penile Inversion Vaginoplasty
MTF – Penile Inversion Vaginoplasty
MTF – Penile Inversion Vaginoplasty
MTF – Penile Inversion Vaginoplasty
MTF – Penile Inversion Vaginoplasty
MTF – Penile Inversion Vaginoplasty
MTF – Penile Inversion Vaginoplasty
MTF
Surgical techniques
very satisfactory
– Aesthetics
– Function
Most difficulty is with
“passing” with clothes
on
Female-to-Male (FTM)
Minority(?) of GID patients
Testosterone significantly masculinizing
–
–
–
–
Voice
Thyroid cartilage
Hair pattern
Muscular development
Surgical options much less satisfactory
– Breast Reduction (“Top Surgery”)
– SRS – Phalloplasty (“Bottom Surgery”)
Local or Regional Flap Phalloplasty
Free Flap Phalloplasty
– Radial Forearm Flap
– Anterior Lateral Thigh Flap
– Fibula Osteocutaneous Flap
Metadoioplasty (meatoplasty)
FTM – Breast Reduction
MTF - Phalloplasty
MTF - Phalloplasty
MTF - Phalloplasty
MTF - Phalloplasty
RFF Phalloplasty
RFF Phalloplasty
MTF - Phalloplasty
MTF - Metadoioplasty
FTM
Surgical Techniques
in need of
improvement
– Aesthetics
– Function
Hormonal Influence –
pass well in clothes
Most difficulty is with
“passing” without
clothes.
Fundamentals of Gender
Reassignment
William M. Kuzon, Jr., MD, PhD
Reed O. Dingman Professor of Surgery
Section Head, Plastic Surgery
University of Michigan