I am a OB/GYN Nurse practitioner and Certified Nurse-Midwife in Las vegas, Nevada. There is a sizable Transgendered population her in Las Vegas entertainment industry and I have had a few of these patients in my practice. I am seeking more information and would appreciate any information you could send me or refer to me. I am considering seeking an opportunity to go to a facility where I could observe the procedures and the after care. I feel very inadequate in my knowledge of the care (long term) required by these patients.   Pamela 

Good afternoon Pamela,

Left a message for you on your home tape, and invited you to spend a few days with us and watch feminizing vaginoplasty surgery (with patient permission) and follow an MTF  patient along post-operatively and perhaps see any others coming into our practice during that time. 

You will learn a lot, but just a one day visit is not enough.  We have several patients from the Colorado area.  Among other things you will learn about suture removal, stent usage, and wound care.    And I believe other surgeons in the western area will be grateful for your expertise.   All for it.

Cordially,

Harold M. Reed, M.D.

Hello Dr. Reed ,

I think that is so much more than fair of you, and again I didn’t mean to appear to take advantage of your kindness..I would never do so, it was completely unintentional.  I will try to get the initial consult fee together as quickly as I can so that we may get things started..obviously any help on your end as far as financial savings you mention in some of the posts  would be extremely appreciated..no matter how much you can afford to help, I know you have bills too.  I did sign up for the site you recommended and have been recieving the emails and post content in my email.  I am really impressed by you, and I am not just saying that.    I truly am overwhelmed by your personal attention to our emails to you..you obviously care for us , the ts ladies, on a level unparalelled in the medical field..I was not expecting this sort of personal compassion from a health care provider at all to be honest, of course..anyone that helps us at all obviously is open minded and a good soul. I really feel that you will indeed help to actually save my life some day through your skilled surgery and I will certainly repay you in the only way I can other than the surgical expenditures of course. I will run my mouth *wink*  I belong to a large network of TG women and I will spread the word of your practice and kindly ethical medical manner to everyone I know in hopes that they will in turn come to you for their surgical needs. You’re a true gentleman above and beyond being a doctor and just a real sweetie, I look foward to actually meeting you some day soon face to face.  In the meantime..I will stop bugging you to death with my incessant emails!  Have a blessed day.

Katrina

Re: Have had a procedure in the US and urinary stream goes forward

Hi Gladys,

Thank you for joining our group MTF-SRS-FTM Yahoo adult group.

Despite a very close placement of the urinary opening to where it should be, just under the pubic bone, post operative tension on the skin surrounding that opening, the vulvar plate, can cause the tissue to rise upwards being pulled upwards by the pubic skin, if that makes any sense.

We have seen 3 such cases this past month, including one from Europe and one from Thailand.

The remedy is really simply as it is better to have more urethra, which can be opened or excised than not enough. That extreme would result in an intra-vaginal urethra and voiding into the vagina.

A natal female’s stream goes pretty much downward, perhaps slightly forward. So if you are hitting the rim of the toilet seat or have to lean forwards to shift the trajectory of the stream behind you, then most likely the opening needs to be re-sited. A plus of doing this is the urethra distal to the opening can be laid open or filleted to create a pink vulva. The urethral opening needs to be flared outwards so it does not contract because  even if the opening is in the correct position, a tight opening is not desirable either.

Urinating on a fresh incision is not a good idea. Anticipate that you will have a catheter in for one week to help form the new opening and keep urine away from your vulva for a while.

All the best,

Harold M. Reed, M.D.

I am post-op. Had surgery on 6/26/2006 by Dr. ….   in Bangkok. I am on HRT forever.Specific_Questions: I have a few problems I feel should be corrected. First of them is when I become sexually aroused, my urethra area becomes so swelled it almost blocks my vaginal opening. It feels lik when I used to get erections. Secondly, there is some hair growing within my vagina and at the hood of my clitoris. Can any of these be corrected?

Nibia 

Dear Nibia,

All of these can be corrected and hopefully to your satisfaction.

The swelling of the urethra into the vaginal canal and limiting penetration is called “a urethral spongiosum rest” or in layman’s word’s…  left over urethral erectile tissue.  A “rest” is something that still persists, that used to belong but remains present with scattered representation. 

This can be remedied by a vertical midline incision over the mass and cauterizing residual tissue and blood vessels that feed the tissue, so  especially when you are aroused it will not swell.

Hair removal is done by a licensed electrologist who has all her equipment in our office and under my supervision can work with local anesthesia and use higher settings to reduce the likelihood of hair regrowth.    This is why we recommend electrolysis well before surgery with followup sessions to be sure all the hair is gone.  What seems simpler, like doing everything at the same time, does not always work and what then.

At any rate, anticipate that we will show you every courtesy.

Harold M. Reed, M.D.

305-865-2000

The periareolar approach is good for size A breast, and will inevitably produce some (hopefully transient) wrinkles as a larger circle is worked into a smaller circle.  The smaller circle being the down sized areolar or pigmented shield that surrounds the nipple.  A way of minimizing  wrinkling is the leave the areolar halfway in size between an ideal male areolar and the original female areolar.   This works well aesthetically only for very big FTM patients, but not so for smaller FTM patients who do not want any tell-tale vestiges of their feminity.

 We are getting excellent results with a free nipple areolar complex graft.  In other words, once removed, the graft is down sized and reapplied precisely in the correct anatomical position judged by when the patient is sat up during anesthesia and after the skin incisions are closed.  Some compression is required for 7 days and this is done with both dressing and a compression garment vest which is essential for all patients to minimize bruising and swelling.

Harold M. Reed, M.D.

This lady had sent in her deposit last year and is doing exceptionally well with a lubricous vulva. Her brother who turns out to be a really nice gent will be spending a few days with her for moral support.

This coming week, revision on a patient with a elongated urethra almost touching her belly button, forgive the exaggeration, and she’ll be converted into a lubricious vulva.

Her former urologist said he knew this was not normal for a woman, but did not know how to fix it.

Harold M. Reed, M.D.
305-865-2000

Hi, I have been fitted with a Mentor silicone elastomer testicular implant a few months ago, but I am unhappy with the texture I found it too hard and not feel enough natural like my other (the real one).I would like to know:1. Do you have access to other type of prosthesis more
realistic and soft than the Mentor prosthesis ?

2. is there a difference between : silicone gel and silicone elastomer implants ?

3. Can I schedule an appointment for an
consultation only? and touch the different kind of
prosthesis?

4. How much will cost a consultation with you ? It is covered by my Quebec health insurance?

Thank you

Reply:

 January 7, 2008

Good morning and Happy New Year,

The technical term for hardness of an implant is called “durometer.”  The lower the number such as a 5, this equates to softness.   Too soft could be runny like a partially cooked egg, so that would not be desirable.  There are also techniques in surface finishing to reduce the possibility of capsular contracture.  

Our office has a vast experience with testicular implants
and we have been aware of the Mentor’s propensity for
capsular contracture many years ago.  Their published results, although the product does have some pluses such as percutaneous volume adjustments.

Yes, I do agree you should palpate demos that we have
in the office and I think you will be quite pleased.
You can initiate a consultation over the phone
by sending us your name, address, and phone number
in an envelope along with a check for 250 and we’ll get
started ASAP.

When you come to the office there is no additional
fee for your first visit.

Cordially,

Harold M. Reed, M.D.
305-865-2000

Done many years ago, elsewhere.  She has recurrent bleeding from the urinary opening and has received the million dollar workup from another urologist unfamiliar with MTF patients, including 2 cystoscopies, flexible and rigid, and MRI and a CT scan, and the obvious left unattended for years.  Her urethra opens almost at the top of her pubis rather than underneath which would be normal for a natal female. 

She notes during voiding the urinary tube which runs over her pubic bone swells. 

Plan… the extended urethra will be opened in the midline, and not discarded, but rather tacked laterally to the sides to create a lubricous vulva with the edges raised to simulate labia minora.  Normal labia minora are characterized by the inside being pink and mucosal and the outside being pigmented.  Her new meatus if possible will be built up or raised slightly as is typical for a normal female and then spatulated laterally or funnelized so it will always stay patulous or open.

This can be done usually under local anesthesia with some IV sedation.  Typically we place Emla or Betacaine ointment on the areas to be injected so the patient will not even feel a needle stick.

 Perhaps we’ll be publishing some pre and post op photos.

 Harold M. Reed, M.D. 

Having an MTF vaginoplasty with reduced fees.

Last year (2008) and the year before (2007) we were very fortunate to have been a research resource for orchiectomy specimens.  Regretfully this relationship was concluded last year.   This was the sole basis of funds for our Grant project with one exception.  A very nice prospective MTF patient made a sizeable donation to help another have an operation.  She herself is on the schedule to be done soon.

What next then.  Well with Dr. Reed, there is always individual consideration.  This does not mean we can work for free, and surgery is a team approach and members of the team such as nurses and anesthetists expect a pay check at the end of their shift. 

However, we have always offered compassionate discounts to those who have enough reserves to cover contingencies and out of pocket expenses.  We do recommend a friend, loved one, or relative stay with the patient for at least 2 to 3 days.  That’s an added expense although we have the availability of attendants, but they bill at about $12 an hour.

Hotel and food for a week adds up to about $650, medications, ring pillow, anti-embolism hose, about $100, stents $350.

As is, our fees are easily about $5,000 below what most  are charging in the US and Canada, and we are busy.

Harold M. Reed, M.D.

As a rule of thumb, you can reduce female hormones by one third after orchiectomy.  My bias is to keep estradiol ranges betwen 125 and 150 to avoid thrombo-embolic phenomena, such as strokes and coronary events.  

An MTF oriented patient wrote yesterday: can he have orchiectomy even if not on hormones.  My reply was yes, but two letters of therapy clearance are needed, one from a licensed therapist with a doctoral degree and another from a therapist with at least a masters degree.   

We can all relate that this is irreversible surgery and all patients should be advised to consider sperm banking just in case there is a change of heart, especally before the real life test.   This individual cannot dress en femme at work and keep his job .

 Harold M. Reed, M.D.