As Published in TGForum

TG Medical: GRS and SRS in the Female Transsexual

There comes a time in the life of a female transsexual when the dream of a lifetime is about to come true. After living successfully as a man for a year or two under the care of a mental health specialist who agrees that your goal of changing your sexual anatomy is both healthy and reasonable, the reality of undergoing gender reassignment surgery (GRS) through sex reassignment surgery (SRS) is upon you. The once female TS, who has reaped the benefits of Testosterone by developing most of the secondary sex characteristics of the human male, must now contemplate the future. The surgery is much more difficult and problematic than for the once male TS. In surgery there must be an axiom somewhere, that says, "It is easier to give than to receive." As in kidney transplantation the donor is at a much lower risk of complications than the recipient. Basically SRS consists of three separate surgeries, each major in themselves and requiring long healing processes of many weeks to months.

First there is the bilateral simple mastectomy or breast removal. Usually performed by a general surgeon or in the case of breast reduction by a plastic surgeon, they require extensive incisions which in some cases may be disfiguring and may require plastic surgical scar revision. This surgery can take up to 4 to 6 hours because the blood and lymphatic supplies to the breast are extensive. Liposuction can reduce the breast size, but not remove solid breast tissue. Healing will take weeks with moderate chest wall discomfort with every breath you take, but you should heal well providing there is no incisional infection. Swelling of the arms is less of a problem since the axillary (armpit) lymphatics will not be removed, but the dissection will be carried to that point.

The next surgery will be an abdominal hysterectomy and bilateral ovariectomy, that is, removal of the uterus and ovaries. This may be done laparoscopically with small incisions or open when it is the desire of the patient to have a vaginectomy with closure. Depending on the size of the uterus both methods can be employed simultaneously with an operating team. The vaginal lining can then be used to form the neourethra of the future penis. And the labia majora can be stretched months in advance with tissue expanders to form the new scrotum. The implantation of solid silicone testes is then very simple.  When discussing this with your surgeon you should refer to pictures as this is complex anatomy. This surgery is very straight forward as witness the large numbers of hysterectomies performed in this country. Sometimes there is excessive blood loss requiring transfusion, but usual recovery is about 2 to 4 weeks to full activity.

Having come this far we can now discuss the most difficult and problematic surgery called phalloplasty. To replicate a functional neophallus or penis, the plastic surgeon desires to create a cosmetic facsimile with sensation and the ability to perform proper intromission and urination. The problem is that there is no other tissue in the human body which approximates penile tissue. So over the years there have been many attempts to take skin grafts from all parts of the body to replicate the penis. This area of surgery has followed the improvements in plastic surgical techniques and microsurgery to the point where free grafts with bone are now taken from the forearm or lower leg and connected to the clitoris with almost the desired result. First a neourethra must be formed months in advance using a hairless skin graft from the upper underarm or vaginal lining. This is rolled into a tube over a catheter and placed under the skin of the leg or forearm until a new blood supply is established. The current standard procedure is the Radial Forearm Osteocutaneous Full Thickness Free Flap which was developed by Chinese surgeons. This requires donation of most of the forearm skin and about one-third of the Radius bone. This large defect must then be covered with a separate abdominal skin graft to the arm with the resulting scars. A similar bone-skin graft has been taken from the lower leg with a scar hidden by long socks. The delicate arteries and veins must be microsurgically attached to the leg vessels through a tunnel and the newly formed penis must be rolled around the new urethra which will carry the urine. This tube within a tube is then connected to the clitoris and urethra to give a free range of motion. The nerve supply of the graft is then attached to a branch of the pudendal nerve to give erogenous and tactile sensation to the graft. Attempts at providing erectile capability using many of the penile prostheses on the market have proven unsuccessful because they cannot be contained within the graft producing skin ulcerations and extrusion. Remember I said almost the desired result. The majority of these grafts develop fistulas with urine leakage which must be repaired  If everything goes as planned without the occasional complications of grafting failure, then most of the successful phalloplasties will have skin sensation and approximately 40 % will have some sexual arousal.

Since penile replantation has been successful following trauma, I can foresee the day when penile transplantation will be successful given the ingenuity of our young surgeons.

Best Wishes in Your New Future,

Cerise Richards, M.D.