by Melanie Yarborough

Dr. Toby Meltzer, the well-known gender reconstructive surgeon recently, spoke at Neutral Corner.

His practice is now over 70% gender related, and he does three to four vaginoplasties per week. His patients have ranged in ages from 18 to 74. He now has a staff of seven, including two nurses, two patient care coordinators, and a Nurse's aid to deal with direct patient concerns. He credits Dr. Biber of Colorado with having done most of the groundwork which current SRS surgeons now build on. Dr. Meltzer himself took over gender surgery from Dr. Bob Demuth, who was then-retiring.  

The gender-related surgeries which Dr. Meltzer practices include vaginoplasty, labioplasty, breast augmentation, and cosmetic enhancements such as voice/tracheal surgeries and facial contouring. The following is not intended to be an elaborate recitation of surgery intricacies, but excerpts from Dr. Meltzer's discussion. Consider it a layman's guide. For specific concerns, obviously consult a professional.

An average vaginoplasty operation takes 3 1/2 hours. Blood loss is relatively small, about 350 cc's. Some patients have asked if they should donate some of their own blood before surgery, should replacement be needed. The doctor says it's usually not, but you can do it if you feel strongly about it.

The average female vagina is 3 1/2" long. Dr. Meltzer's average reconstruction comes out 5 1/2-7", which should be more than enough. Feeling, especially regarding intercourse, is a concern to many transsexuals. Dr Meltzer reassures us that he does not cut glands, but retains them and uses them to create a neocervix. After the surgery, one may go through a period of sensory reduction. However, as glands are not severed, it's just a matter of learning where everything now is and adjusting to new sensations.

In vaginosplasties, one of the biggest issues of concern is the interrelation of the rectum and the new vagina. If not done properly, a fistula can develop, an abnormal connection between the two. As Dr. Meltzer puts it, this can be "a really ugly concept", which can be avoided by proper technique. He notes that doctors who do this surgery only periodically find it one of the most delicate and difficult parts of the operation. Because of this, he recommends going to a specialist: "This was the probably the biggest learning curve for me. It pays to go to people who've done this before".

A labioplasty is considered a "nice enhancing operation...half cosmetic and half create a more natural looking vagina". After initial reconstructive surgery, the new vagina has mostly labia majora. The additional surgery is for thinner labia minora as well. Or, the operation can be used to smooth out or cover any initial transverse or oblique scars. It also allows a surgeon to create clitoral hooding to protect the new clitoris, which is not done in the initial procedure.

For breast augmentation, he uses saline implants underneath the muscle. Such implants may tend to wrinkle, so it's best to have them not as visible. He advises his patients "You're skin's never been stretched, you've never been pregnant". After 3 months, the new breast tissue will settle.

The tracheal shave removes no more than 50% of the tracheal cartilage, that prominent Adam's apple in so many genetic males. It should do no damage to speech or swallowing. It is only an issue if it cuts into the vocal chords; then, it could lower the voice. For voice surgery itself, Dr. Meltzer works with a specialist, Dr. Cohen. They try to avoid cutting and pulling forward vocal chords, only doing it if necessary. Instead, they try to narrow the space between the thyroid and crycocartilage. The Doctor notes that laser thinning doesn't seem to have as good an effect and can affect voice clarity. He has done this kind of surgery for 3 1/2 years, and says it is a reversible process. Patients should be advised that it may take 6 months for a vice to drop down to a normal female pitch.

In addition to genital and breast surgeries, Dr. Meltzer does facial contouring as well. One procedure is cheek implants. A smooth implant is placed over bone, which increases the width of the face. This creates a more oval and feminine appearance. This can also create the appearance of reducing a masculine jawline. A rhinoplasty can be done to narrow the nasal bones, and a lip lift can create a fuller upper lip. And there's always the standard facelift to create a higher, cheekier appearance.

There are several significant things to note regarding gender surgery:

-When legs are immobilized for a long period of time, especially through being bedridden, circulation problems can result. At Dr. Meltzer's facility, efforts are made to get a patient out of bed and exercising the muscle as soon as possible.

-After surgery, it's important to get a periodic gynecological pap smear. Contrary to popular belief, this test is not just for the cervix only. It's a staining technique to look for any cancerous cells. And yes, penile tissue can sometimes develop cancerous growths.

-Regarding psychological issues, there is a tremendous endorphin release which creates the initial sense of euphoria after surgery. However, it's normal to have a post-operative depression when one comes off these endorphins. Moreover, there's the realization that a big life event is over. However, this depression is short-lived.

-Sexual reconstructive surgery for transsexual teenagers is still a problematic issue. Although a Netherlands study has shown that patients under age 18 have done well, it is still touchy with most Doctor's malpractice insurance companies. A parent's waiver means little, it can always be disallowed by a judge holding that the child did not know what was at stake.

-The issue of private insurance or public state medical funding for reassignment surgery is also still a tough political issue. Many states, such as Oregon where Dr. Meltzer practices, have a rationing system of what will and will not be covered. This prioritizing is very black and white, and the likelihood of SRS funding is low. Dr. Meltzer is very careful to state that in such issues, he does not deal with the press. He respects the privacy issues of his patients. He estimates that no more than 2% of SRS patients are able to have the operation covered by insurance.

Dr. Meltzer can be contacted at:

1500 SW First Ave, Suite 1120
Portland, OR 97201-5835
(503) 525-9323

email: [email protected]

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