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Polare 36 >> Article 4
Transmen
Phalloplasty Stage 2 by Michael
Okay, this is the big one, the last and final stage where the penis is
fashioned from a flap from the forearm. The arm is used, because the
blood and nerve supply is excellent for the penile graft.
This stage can be done three to six months after the first stage which
I described in Polare Edition 35.
For this operation you have to be in the best physical, mental and
emotional state that you can be in.
If you are a smoker, please try to cut down or if you can, give
cigarettes up completely two or three months before the surgery date.
If you're carrying a bit of excess weigh, try and loose it, cut out
junk food and go slow with alcohol.
Exercise and work at being in the best physical shape as possible.
This preparation is very important.
This is a huge operation which can take from five-seven hours, there
is a lot of trauma to the body both physically and emotionally,
approach this as if you are running the marathon of your life. You
should prepare yourself mentally in the same way, put your mind in
order the same way you put your body in order.
Learn some meditation techniques to de-stress yourself so that if a
problem arises you are able to cope more easily. Make sure you have no
work problems, money worries, try to have everything in order.
Organise a support network with your partner, family and friends so
that whilst in hospital and recuperating at home you have help if it
is needed.
Some of these things I did, but a lot I didn't and paid the price
quite highly.
I moved to Victoria in late January thinking that two months was
plenty of time to organise all of the above. I was so wrong. Even
though through the kindness of people I had just met, my accommodation
problems were solved, I still hadn't stopped smoking and I was very
stressed out over a lot of things, so that by the time I entered
hospital I was physically and emotionally exhausted and in no fit
state to cope with what was to come.
Please organise your life well before surgery so that the healing
process can proceed smoothly.
In Victoria this procedure is now well advanced and a lot of the
problem areas have been solved. The Surgical team have performed about
fourteen of these procedures with a high success rate.
The most common problems are Strictures (scarring) and Fistulas
(leaks), for myself I had minimal problems in these areas and am
delighted with the end result. This was the last stage of my journey
towards completions and the start of the rest of my life. I was very
aware of my physical state but was very confident that these would be
no major problems with this operation.
I returned to Peninsular Private Hospital on the sixth of April and
met up with all my old friends there, it was good to see them all
again and to know that they were there to support me on all levels.
The operation was scheduled for 7.30 am the next morning so all prep
work was done that night. The anaesthetist explained what he would be
doing during the operation as well as the pain relief regime post
surgery.
I had asked Dr Hunter-Smith (David), if one of the nurses, Sue, could
take photos of the operation because I was very interested in knowing
what was going to be done. When I was wheeled into theatre he told me
he would video it for me if I wanted. That was the last thing that I
remembered.
Thankfully I have the photos and video and have been able to see what
was done.
Once asleep a tourniquet is put round the upper arm to cut down the
blood supply to the donor site. Dr Ceber then draws a diagram, like a
pattern, on the arm, measuring very precisely according to the size
you have asked for. He then proceeds to cut and fashion the penis.
This is all done with some blood vessels still attached to the arm so
that it stays alive. The soft skin on the underside of the arm is
rolled into a tube to form the urethral extension. A penile catheter
is inside this tube to keep it open while it heals. It is placed in
the centre of the skin flap which is now ready to be formed into the
penis.
The head has been defined and once the shaft is sewn up, the head is
joined and stitched. Once this has been completed it is detached from
the arm and handed to David who has been preparing the site in the
groin to receive the penile graft.
The arm is now ready for the skin graft which has been taken from the
upper thigh. This skin is stretched until it looks like mesh. This
enable it to cover the wound site completely so that it adheres to the
exposed muscle. The graft is attached by staples and once completed
the arm is dressed and splinted for support.
This procedure takes about four hours. Meanwhile, David has already
started attaching the penis. This is a long involved process and
requires micro-surgery for it to be successful. The two urethral ends
are joined then the blood vessels and arteries and nerve ends.
The penis itself is stitched onto the body. Drain tubes are put in
place and a supra-pubic catheter is attached. Once all this is done it
is closed up. I had requested that larger testicular implants replace
the ones I had in the first stage surgery as I felt they would be more
in proportion to the size of the penis. This was the final part of the
operation.
It was about 9.30pm when I woke in my room. It had been a long day for
all of us. I was on a drip infusion of pain killers and hourly obs are
taken of the penis to check for warmth, skin return and to make sure
that it is kept straight and supported. This support is done with foam
rubber.
The arm and hand are also checked to make sure there is no loss of
sensation and that the fingers move and do not go numb. The first few
days were quite a blur because of the pain killers but as these were
eased off, I became more aware of what was happening. Staples are used
on most of the wound sites and on Day 6 the drain tube in the groin
and the staples were removed.
Day 8 and the remaining drain tube and the penile catheter is removed.
All this was relatively painless. I was up and moving around very
gingerly as I was suffering from a type of chronic fatigue. This
really slowed the healing process for me so that I took everything
very slowly. I didn't want anything to go wrong. I wasn't in a hurry
to rush off anywhere and felt that if I took my time, everything would
be more successful.
Day 9 and the plaster and dressing came off my arm and it redressed.
At this point it has to be kept dry.
Day 10 - I was able to go to the bathroom so that I could soak the
dressing off my leg, keeping the arm dry. This was relatively easy and
was not too painful if done slowly. The graft site looks like a burn
and once the dressings are removed an op-site dressing (plastic skin)
is put on and left in place. It is more uncomfortable than painful.
At this point I had virtually no use of my hand and arm and needed a
lot of help to bath and dress etc. It was also very painful at times.
The pain seemed to come from nowhere. It was very throbbing at times,
then the pain would disappear as quickly as it came.
Once you are up and walking around the penis must be supported. It
must not be bent at all as there is the danger of kinking off one of
the two main arteries that feed the penis. One artery takes blood into
the penis and the other takes it out. It is very important not to
damage them. Sue devised a sling that I could wear so that I could
walk around easily and no one would know why I was in hospital.
Day 13 - I soaked the dressing off my arm in the bath and it was then
washed and dressed daily. The healing process was already underway and
it improving rapidly. By this stage I had been on antibiotics for two
weeks and again suffered a thrush infection down below. If you are
susceptible to this problem, be aware that it is possible to get
repeated infections in that area.
Day 19 - and the staples were removed from my arm. A bit painful but
healing very well and already starting to fill out. Some of the
stitches were removed from the base of the penis and a small raw patch
at the base was treated three times a day with solu-gel to hasten
healing. This is where in some patients problems have arisen. By now
the patient has started to urinate and as the raw patch corresponds
externally with the urethral join internally, leaks have occurred.
David wanted to wait until this had healed before I attempted to pee.
Day 25 - the remaining stitches are removed from the base of the penis
and I was able to walk without the sling. The next day sounds, which
are long metal rods, are passed through the urethra to dilate it - not
a pleasant experience.
Day 27 - I attempted to pee but had a leak from the original site from
the repair done in November last year. I was very disappointed, back
to the theatre again, and another wait of 10 days.
Day 34 and five days after the repair, sounds were again passed to
dilate the urethra. This stretching is very important to stop scar
tissue building up and keep the urethra open. This was now done daily,
some pain was experienced each time.
Day 10 arrived and David passed some dye through the urethra to check
the repair. It was successful. There were no leaks anywhere.
By now I had been on the catheter for 39 days. I was having problems
with it constantly and had a bladder infection. This catheter had been
resited when David did the repair but because of the infection, it was
constantly blocking. It was treated with intra-venous antibiotics and
cleared up quickly.
Day 39 and the 11th day of the repair. Pee day had arrived --. After
this length of time on the catheter, it is very difficult to pee, let
alone pee from my new penis. It is a matter of clamping off the
catheter, and trying to go naturally without straining and it took me
the whole day before I had a successful result. It was very exciting
and such a relief that this was really happening after all this time.
The catheter remains attached until you are voiding large amounts
through the penis and the residual left from the catheter is quite
small. Dilation is done every day over this period and was still
painful.
Day 44 - it was time to leave hospital. It had been six weeks this
time. I had gone through a lot physically and emotionally. There had
been times when I was ready to give up, when I couldn't be even a
little bit enthusiastic about what I now had. I went through many
emotional stages which I feel everyone needs to be aware of.
I went through a grieving process many times and found a lot of old
"stuff" came up. Things I thought I had dealt with years ago came up
again, and the issues that were happening now had to dealt with. I had
a period of depression but thankfully had a lot of support from the
nurses in hospital and once home, from the people I was staying with.
They helped me get through it all. I don't think that I will ever be
able to repay them adequately.
The nursing staff were very supportive and were always there in every
way. Again as in the past, Sue came to the rescue many times as did
David. They were aware of my fears and really understood my
apprehension at each stage of the process and let me go at my own
pace.
It is now nearly four months since my surgery and my arm has healed
and is filling out. I have full use of it and except for some numbness
around the wrist, I have no problems with it at all.
I am very pleased and proud of my penis and it is great to have the
feeling of freedom that comes with it. At this stage there is still no
feeling in it. This can take up to six months to happen. Before you
can have the penile implant inserted full feeling in the penis must
have returned.
This has been my story, the problems that occurred where also mine.
Yours may not be the same. Progress has and is being made very rapidly
and I am glad if some progress has been made from my experiences.
I hope that I have been able to answer many questions and give you all
enough information so that you can make the choice that is right for
you.
Thank you,
MICHAEL
pathways_au@yahoo.com.au
Tel: (03) 5975 8916 Victoria, Australia
It should be noted that this article was reproduced here for the
information of the F2M community, the Transgender/Transsexual community, partners, friends and family.
It is not in any way a Gender Centre endorsement of the particular
surgeon or procedures
Polare is published in Australia by The Gender Centre Inc. which is funded by the Department of Community Services under
the SAAP Program and supported by the NSW Health Department through the AIDS and Infectious Diseases Branch. Polare provides a forum for discussion
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Opinions expressed in this publication do not necessarily reflect those of the Editor, The Gender Centre Inc., the Department of Community Services
of the NSW Department of Health.
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