The Reed Centre for Genital Surgery
Harold M. Reed, M.D.

A. Metoidioplasty or Metaidoioplasty (phallic clitoral enlargement, stand to void) - Sex Change Surgery
The procedure confers the advantage of minimal surgery with preservation of natural sensation and erectile function.  Donor site forearm scars avoided. Overweight patients may achieve greater length with pubic lipectomy which will recess the body surface line.

In this sex change procedure the clitoral hood is lifted and the suspensory ligament of the clitoris is detached from the pubic bone, allowing the clitoris to extend out further.  When the female tissues have been primed with testosterone, the clitoral head may resemble an adolescent glans penis.  An embryonic urethral plate must be teased away from the underside of the clitoris to permit outward extension and a visible erection.

For those patients who desire to void standing after this sex change proceedure, the urethra is extended into the neo-penis. This may be accomplished simultaneously or performed secondarily using either a vaginal flap or buccal mucosal graft.

Please understand in that metoidioplasty (sex change surgery) involves a fair amount of tissue transfer, some degree of post-operative swelling is expected.  Complications may include but are not limited to less than anticipated length, torquing of the clitoris (usually amenable to release), loss of sensation, tissue necrosis, localized infection, persistent tenderness or hypersensitivity, transient or permanent narrowing of the vaginal opening which may render the vagina incapable of penile penetration, urethral narrowing, urethral obstruction, and urethral fistula (leakage of urine anywhere along the pathway of urethral extension).  Between the first and second stages leading to urethral extension, voiding patterns and trajectory may be forwards or backwards and may splash wetting perineal, labial and vaginal skin.

B. Penile Implantation for the Neo-Phallus patient.
A penile prosthesis confers the wherewithal to penetrate which may be the defining moment for a successful conclusion to gender reassignment surgery.  Clearly the intimacy of complete sexual contact is sought equally by patients and their partners.

C. Insertion of Testicular Implants into Labia.
This should be performed as a procedure unto itself or with urethral extension to minimize complications.  To prepare the labia majora for implantation, a tissue expander may be employed for a few months.  This also creates a more pleasing scrotal appearance.

Labiaplasty - (Labia Minora Reduction)
Labiaplasty is offered to women with excessive, redundant labia who suffer from unsightly contour lines and physical discomfort.  Such women report pinching or chafing when sitting or walking, hindrance during intromission, and difficulty maintaining hygiene during menses or after defecation.

Overly pigmented and unattractive labia can be reduced with a V-plasty technique that converges freshened margins in a neat concealable line.  Delicate, minimally reactive, self absorbing plastic surgery suture is employed.

Pre--operative expectations are discussed in a relaxed environment.  Reassurance regarding normal variation is provided.  Areas of intended excision are delineated for patient approval with hand held mirror.

Surgery can be performed on an outpatient basis.  Sexual activity may be resumed in 6 weeks.  Excessive clitoral hood tissue may also be trimmed during this procedure as requested and is covered by our comprehensive fee.

Breast Augmentation
Breasts are universally recognized as a symbol of nourishment, love, femininity and sexuality. Breast augmentation is the second most popular cosmetic procedure performed (following liposuction), about 254,000 cases per year in the United States.

Breast prostheses applicable for standard implantation are typically saline filled and those for reconstructive surgery may be cohesive silicone gel filled.  Cohesive gel implants when cut on the laboratory bench maintain their shape and do not leak.  Perhaps in a few years cohesive gel implants could be used without restriction.

Prostheses come in difference profiles and some are anatomical in shape, i.e. tear dropped, being fuller in the lower pole.

The average expectancy of a saline filled breast prosthesis is about 16 years.  However the likelihood that revisionary surgery will be performed within 5 years is about 25% across the board.  The most common reasons for implant replacement are for request of size change 37%, leakage or rupture 24%, capsular contracture 18%.

Compare this with a 3% incidence of re operation in Dr. John Tebbetts series involving about 1662 patients with a 7 year followup.  Careful matching of the implant to the unique anatomical features of the patient explains this.

Generally I subscribe to the Tebbetts formula for appropriate size.  Oversizing creates many problems including early drooping (pendulous weight effect) and "double bubble."  A distortion when the base of the implant below is seen distinctly from the base of the natural breast, above, which is of lesser circumference.

Breasts as they occur naturally are not perfectly symmetrical, "sisters not twins."  Some balance can be achieved by differential filling and placement.  Cleavage does not occur naturally and attempts to place implants so close as to achieve this may result in synmastia, the touching of one breast prosthesis against another.

The subpectoral approach is desired especially when pinched skin thickness is narrow in the upper pole (that breast tissue above the areola).  This provides greater coverage of the implant.  However, an implant is seldom entirely covered by the pectoralis muscle and is really bi-planar, partially sub-glandular in the lower outer quadrant where the pectoralis muscle is absent.

Athletes should avoid a subpectoral approach as it might impede pulling.

The two most popular in incisions are inframammary and periareolar.  Other procedures include transaxillary (through the arm pit) or transumbilical.

The early detection of breast tumors may be slightly enhanced with prostheses although there may be some technical problems with compression during mammography.

Scarring can be minimized by taping over the incisional area for 3 months.

Massaging post implantation may reduce capsular contracture which can occur in 8 percent of patients, but can also result in some migration secondary to broadening of the pocket.

Anticipate a variable degree of pain for 3 or 4 days, associated with tissue stretching.

With respect to the ability to successfully breast feed after breast implantation, one study reported up to 64% of women with implants who were unable to breast feed compared to 7% without implants.  The periareolar incision site may significantly reduce the ability to successfully breast feed.

Male Chest Reconstruction
Male Chest Reconstruction usually precedes below the waist surgery for FTM patients as protruding breast contours are a sin quo non of the female presentation.

While for very small breasts a peri-areolar skin excision can be performed, the problem of maintaining an adequate pedicle to support the nipple areolar complex without protrusion of the pedicle through the skin becomes challenging. Bringing skin into the borders of a contracted areola will cause puckering which hopefully with time will smooth out.  A permanent fixation suture is often required to prevent tension on the suture line from causing a slowly expanding scar.

A transverse inframammary incision with free nipple areolar grafts is my preferred approach. If there is too much blousing of the skin, the alternatives are to extend the incision laterally (chasing a dog ear) or to make a vertical midline incision (inverted T).

The areola is trimmed to a pre agreed upon diameter and the nipple sectioned with a pie shaped excision and reconstituted.

Although the patient must be cautioned there may be varying sensory loss because of nerve disruption, our limited experience has been favorable in this regard as distal nerves are known to regenerate.

Nipple areolar grafts must be kept wet with saline soaked gauze re-moistened every 3 hours for at least 5 days to maintain tissue viability until capillary buds grow into the graft.

Plan on having a roommate or spouse do this for you throughout the night.

Some crusting of the grafts is not unusual and will usually shed by the 3 or 4th week.  By all means do not lift or pick them off as the adherence of the graft may be very tenuous and its viability very fragile.

After tissue settling some revision surgery may be required and is usually done for a nominal fee relating only to use of the facility and anesthetic services if required (as opposed to being done under local).

Breast sizes greater than a C, need to be done in hospital setting.

Description of Other Procedures Performed:

Penis Enlargement / Phalloplasty
Dr. Reed has been performing penile enlargement surgery since 1986.  The procedure involves as needed release of the suspensory ligament, pubic liposuction or dissection, and taking down of the "turkey neck" deformity (peno-scrotal web).  That portion of the penile shaft under the skin is about as long as the pendulous penis and assumes an arched course under the pubic bone.  Release of this arch allows the penis to protrude further outwards.

Foreskin Restoration
Foreskin restoration has been described even before Celsus, the first great Roman physician (25 B.C. to A.D. 50), wrote "De Medicin."  The procedure used today is only somewhat modified from what had been done then so "the patient could move around inconspicuously in Greek and Roman society."  Celsus drew heavily on his Egyptian and Greek predecessors.

Peyronie's Disease Correction
Peyronie's disease, named after the french surgeon to King Louis XV, is a restricting scar or plaque that exists in the lining of the erectile bodies resulting in a tethering of erections ("bent spike syndrome"). The cause is now thought to be repetitive trauma. An unappreciated example would be female above trauma which may occur after the penis momentarily slips out of the vagina. Autoimmune basis for plaque has also been ascribed. Peyronie's disease may co-exist with Dupuytren's flexion contractures of the hand.

Circumcision
A circumcision is perhaps the highest cosmetic calling given to a urologist. We do several circumcisions and a few revisions here every week, as we enjoy a reputation for excellence and exactitude when it comes to cosmetically performed adult circumcisions. We operate within tolerances of 1/32" or about 1/2 mm.

Gynecomastia
Gynecomastia or enlargement of the male breast may produce an unwanted feminizing appearance. This is typically caused by an increase in stromal (connective) and ductal tissue, however a serious underlying cause should always be considered. The incidence of occurrence in naval military exams is about 8 in 100,000. Gynecomastia is noted normally to some degree in pubescence with incidence as high as 65% in boys aged 14 to 15 years.

Vasectomy / Vasectomy Reversal
Vasectomy is a safe and effective means of permanent contraception. Approximately 500,000 vasectomies are performed in the United States every year. This procedure performed under local anesthesia takes about 10 minutes. The experience of the surgeon is the single most important factor assuring a smooth convalescence. Vasovasostomy or vasectomy reversal is a urological procedure to re-establish fertility. 500,000 men each year have a vasectomy in the United States, and ultimately 2% to 6% will request reversal. The most common reason is to produce secondary offspring following remarriage to a younger woman. This procedure offers the best degree of technical success when performed microscopically, because finer sutures are less likely to produce obstruction of the internal channel at the reconnection site.

Testicular Enlargement
Testicular enlargement (enhancement) is a procedure to better fill the scrotum using testicular implants which are ovoid in shape and are placed in front of your existing testes. Rather than a fluff bag appearance of the scrotum created by scrotal fillers, the pleasing contours of two well represented gonads are noticeable. 

Penile Prothesis Implants
Approximately 10% of all adult males are impotent, and of that group, only half really care. Implantation of a penile prosthesis is one of many options available to these erectilely impaired, and should be looked upon as a last resort. Other alternatives include oral medications, urethral suppositories, intracorporeal injections, vacuum erection devices and behavioral modifications.  Specially qualified patients with focal areas of arterial occlusion may consider penile revascularization.

Visit Dr. Reed's Other Sites: Penis Enlargement Testicular Enhancement Vasectomy Reversal Cosmetic Circumcision Male Breast Reduction Peyronie's Correction Penile Prothesis Implants

Sexual Reassignment Surgery (SRS) / Sex Change in Miami
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