Sex reassignment and plastic surgery with Dr. Pierre, Brassard, Montreal, Canada

One year ago on this very day,i was driven to a place so far away.

I met a handsome Doctor with a smile so bright, he said ” No need to worry, everything will be alright”.

It was a  beautiful sunny day,  i was takin upstairs to the top floor, my new life awaited me behind the closed doors.

My heart was pounding , my mind racing fast, all the inner sadness would soon be in the past.

The staff worked quickly, I was amazed to see, they were minutes away from working on me.

I broke down in tears and felt such relief , the thoughs of being complete , left me in utter disbelief.

I awoke a hour later my life flashing before my eyes, the pain that was about to begin, was an interesting surprize.

I was surrounded by new friends, and a much caring staff, we all did our best to make each other laugh.

We were random strangers right from the start, but bonding together, we became sisters at heart.  

The journey was over time to go home, not for a second, did i feel, sadly alone.

A year later i can honestly say, I don’t regret a thing , i am so much happier this way.

Thanks again to everyone ,  all of you are amazing caring people, i miss you all.

Love,     Brooke.

Post operative dilation and douching instructions

Dilations

Healing after a vaginoplasty lasts one year.  Keep in mind that the success of this surgery depends on maintaining the length, girth and depth of your new vagina.  To achieve this, you need a set of 4 dilators and respect the instructions below. Do not stop dilations without advising your surgeon.  Stopping dilations will cause the loss of the vaginal canal and is irreversible without further surgery (skin grafts or bowel transposition).

Relaxing

Relaxing is the key step.  It will make dilations much easier.  Taking ten slow deep breaths before beginning is one good way to get rid of tension.

Angle

After you have localized the vaginal opening with a mirror, insertion should be made for the 2 first inches with a slightly downwards 15° angle.  Do not go directly towards the rectum.  After that the angle should be corrected so that the dilator becomes almost parallel to the bed while trying to aim at the navel.

Pressure

Insertion should always be gentle and slow.  When the dilator is inside the vagina for the entire length, apply constant not forceful pressure.  Gaining depth by applying more pressure is not advised.

Dilation instructions

Wash your hands

The first day of your dilations, the attending nurse will show you every step of the process.

-       Hold dilator #1 like a pen

-       Apply about one teaspoon of lubricant gel on the tip of the dilator

-       Insert at a slight downward angle for the 2 first inches

-       Leave dilator inside 5 minutes; remove slowly

-       Repeat with dilator #2 for 15 minutes

The second day of dilation can be more difficult because of swelling that sets inside the vagina during the night. It is perfectly normal. Be patient.

You should gently and frequently wipe out the gel that is coming out at the bottom of the vagina.

Wait 3 months before having intercourse.

DILATION SCHEDULE

At the residence

You should dilate 4 times per day.

Day of traveling

You should at least dilate once before leaving the residence.  If you have time, dilate more that once before your departure.  Even if you have a long day of traveling and you cannot dilate for hours, you should plan on doing at least one dilation when you arrive at home.  Please be active on the plane.  Walk as much as you can.

Home

Resume your schedule as soon as possible.

At home, you should dilate 4 times per day with, #1, #2 for 5, 15 minutes for one month.

Dilate 3 times per day with #1, #2, #3 for 5, 10, 15 minutes for two months.

Dilate twice a day with #2, #3, #4, for 5, 10, 15 minutes for 3 months

Dilate once a day with #3, #4, for 5, 15 minutes for 6 months.

Slowly increase the interval of time between each dilation until you reach one dilation per week with #4, for 15 minutes for the rest of your life.

If you have difficulties with a bigger size dilator, wait before you are comfortable with this one before using a bigger size.  You can go back to a smaller size and increase the frequency for a few days.

CARE FOR DILATORS

Wash the dilators after each use with non-abrasive antibacterial soap in warm water and dry thoroughly.  Do not wash them in the dishwasher or clean with alcohol.  This could damage them.

While at the convalescence home, the dilators are kept in Hibitane,  Dexidin 4 or  Hiciclens 4  to find in pharmacy.  25ml of solution in one gallon of demineralised water) Use one or the other solution.  After 2 months, store them in a clean and dry place between dilations.

In two months, stop: vaginal douche, soaking your dilators and sitz bath.

The Polysporin cream is for 10 days.

Maintain at least 2 hours intervals between dilations (from the time you finish one and the time you do another one, 2 hours minimum.

DOCHING INSTRUCTIONS

Vaginal douches are to remove remains (sloughing) should be done every morning and evening.  Douche first thing in the morning before your first dilation and the last thing at night after your last dilation.

-       Re-use same applicator

-       Insert the applicator 2 to 3 inches deep

-       Squeeze hard to give a good spray inside the vaginal cavity

-       Refill the bottle with a solution of ¼ of a cup of vinegar in 1 gallon of demineralised water and fill up your bottle everyday or use disposable douches.

Douche twice daily for the first two months.  By then the return should be clear.  After two months, stop douching long term.  Douching will alter the vaginal natural flora and cause imbalance.  This is why douching is not recommended as a routine after two months.

After that if you experience an unusual discharge and odor, you can resume douching twice daily to correct the bacterial imbalance.  If there is no improvement after a few days, you can try an alternate solution with Betadine (one part in 3 parts of water), if you are not allergic to iodine or shellfish.  If it does not correct the problem, make an appointment with your primary care doctor.

TYPICAL DAY SCHEDULE

It is very important when you are in bed to leave your genital parts air open.

On the last september 17 th 2009, the The Endocrine Society had adopt a new guideline on transsexuals treatments. Here is the press release on the last week:

Chevy Chase, MD—The Endocrine Society has released a new clinical practice guideline for endocrine treatment of transsexual persons. The guideline, “Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline,” appears in the September 2009 issue of the Journal of Clinical Endocrinology & Metabolism (JCEM), a publication of The Endocrine Society.

• The diagnosis of GID be made by a mental health professional;

• Against endocrine treatment of prepubertal children because a diagnosis of transsexualism in a child who has not yet gone through puberty cannot be made with certainty;

• Treating transsexual adolescents when they first exhibit signs of puberty by suppressing puberty until the age of 16 years, after which cross-sex hormones may be given;

• Treating transsexual adults by suppressing endogenous sex hormones, maintaining physiologic levels of gender-appropriate sex hormones and monitoring for known risks.

“The medical field will need further rigorous evaluation of the effectiveness and safety of all endocrine treatments of transsexual persons,” said Hembree. “Of specific concern are the effects of prolonged delay of puberty on bone growth and the long-term medical and psychological risks of sex re-assignment.”

Other members of the task force that developed this guideline include Peggy Cohen-Kettenis and Henriette Delemarre-van de Waal of VU Medical Center in The Netherlands; Louis Gooren; Walter Meyer of the University of Texas in Galveston, Tex.; Norman Spack of Harvard Medical School in Boston, Mass.; Vin Tangpricha of Emory University in Atlanta, Ga.; and Victor Montori of the Mayo Clinic in Rochester, Minn.

You can also read the old work document about it from 2008

Nicky Phillips says gender is not either/or

Nicky Phillips, shown in her Richmond neighbourhood, has never thought of herself as anything but a woman, yet a genetic test would show she is a man. Photograph by: Ward Perrin, Vancouver Sun

Nicky Phillips never thought of herself as anything but a girl.

As a child, growing up in the 1940s and ’50s, she wore little-girl dresses, shiny shoes, and bobby socks. When she got a bit older, she started to wear lipstick and pearls and fuss about her hair.

Puberty brought with it the same uncertainty and awkwardness it brings most young women. But in Phillips’s case, her body wasn’t changing in the same ways it was for other girls.

She never got her period. She didn’t grow any underarm hair and had very little pubic hair. But she had an aunt who also never menstruated, so she never thought of it as anything out of the ordinary.

In her teens, she found out she didn’t have a uterus and would not be able to have children.

Read more on Vancouver Sun

Here are some guidelines and information that I have learned over the years after 1500 SRS in regards with M. to F. SRS. They should be read with an opened mind. They will certainly be improved for accuracy .Anyone who cares genuinely for an SRS patient will realize that we have still much to learn and that the patients should be praised for the courage they show during a long and difficult journey. Fortunately most will be relieved after surgery and live an happier life. I welcome questions, observations and calls if you are caring for a patient of mine.

Appearance

In most patients the vulva looks swollen and bruised and the bruising can extend to the groins and upper thighs. There is either  a crust ,a piece of gauze and/or blood clot on the small lips. The clitoris is invisible, it is hidden between the small lips and behind the hood. It becomes visible after 4 to 6 weeks. There can be a small dehiscence at the posterior entrance (fourchette) where the tension on the incisions is greatest. The opening of the urethra (meatus) is difficult to find visually ,it is located immediately above the entrance of the vagina. The inner lips will start at the hood and continue downward to the meatus of the urethra. They can be quite swollen and asymmetric during the first month .The bright red inner lining is urethral mucosa will become pink in time ( 1 year).

Swelling

It is considerable for months. One will see that it goes slowly away for a good year. It is surprising to observe that the vulva changes so significantly for 9 to 12 months. The details of the vulva will refine over that period of time. Some asymmetry can become evident but it will gradually improve back to the immediate postop symmetry.

Stitches

There are 2 types of sutures (vicryl and monocryl) that are used. All are resorbable. Some take 21 days to resorb others will take 60 days. Knots and strings can be seen along the process. The knots should be left alone and the strings gently pulled and cut. They can also be ignored if they are not annoying because they will resorb on their own.

Bleeding

Bleeding in small amounts is usual for 2 to 4 weeks after surgery. It should never be enough to drip and make clots. In that case there is a bleeder that needs to be addressed. Local pressure should be the first reflex for 10 minutes. Slow daily bleeding is secondary to unhealed surfaces inside or outside. Most surfaces will heal quickly during the first month thus reducing the bleeding. Granulated areas that are friable can cause chronic bleeding.

Skin slough

Because most of the lining inside the vagina is made of grafted skin, it is common to see pieces of “dead skin” coming out of the vagina. What is actually seen is superficial layers of graft peeling off.If they hang loose they can be cut off without pulling. Contraction, reepithelialisation and healing of this will happen in time. It is not possible for the lining of the vagina to come out, although patients may fear it.

Urination

The urinary catheter is removed on the 6th day postop. At first urination can be in one stream and quickly become one big spray. This is normal and seen in all patients and can last 2 to 4 months. Beyond that period, if still present, it can be caused by an irregularity at the meatus. This will be addressed surgically only one year postop.

Urinary tract infection

Because the vaginoplasty causes limited nerve damage around the prostate, sphincters and bladder it alters the normal physiology of urination. Added to that is the fact that the urethra is shorter and thus germs are closer to the bladder making patients prone to bladder infection. Keeping  urine clear and proper urine testing pre and post treatment are indicated. In general patients will develop bladder infections in the few months after their surgery. The proneness to this problem tends to disappear after 2 to 4 months.

Granulation tissue

The granulation tissue is a normal finding in the M to F patient. It occurs most often at the posterior entrance of the vagina (fourchette).If kept clean and flat it will heal in time. It can be of variable extent and is caused at the fourchette by tension at the incision. One way to reduce tension is to make sure that while sitting there is no upward traction of the buttocks. Simply a patient should sit straight and not slide on the chair…If the granulation tissue becomes thick or pedicled it cannot heal on its own and needs the application of AgNO3 (silver nitrate) which is available to any doctor or nurse. The AgNO3 will cauterize it .This treatment may need to be repeated every 2 weeks until it is healed. We think that thick granulation tissue is caused by  germs and  also needs some kind of topical antibiotic like sodium fusidate cream. Granulation tissue may appear anywhere in the center of the vulva and should be addressed the same way.

Ointment

In general patients will use polysporin on the incisions after surgery. It should be discontinued after dilation day number 10.Beyond that the ointment tends to irritate the skin.

Discharge

Colored discharge is part of healing in some patients. During the first 2 months patients will douche and bathe twice a day to have proper hygiene. Color and odor will be controlled well with the hygiene measures that patients learned at the convalescence house. Increasing pain, with changed color and full odor are signs of acute vaginosis and should be treated accordingly (cultures, systemic antibiotics, close follow-up on the treatment efficacy).In general patients should obtain within their 2 months of douching a clear return of  the douching solution (absence of blood and discharge) and stop douching after 2 months .Discharge and/or blood beyond 2 months is tolerated somewhat for another 2 months after which it should be considered a low grade infection .Visual examination of the cavity is to be considered. If granulation tissue is found in the cavity is found it should be treated with AgNO3 every 3 to 4 weeks and metronidazole gel 1%.The gel should be used sparingly with the applicator or as a lubricant during dilations until discharge has subsided ( sometimes for weeks…). Oral Metronidazole 500mg twice daily for two weeks usually is given at the beginning of the treatment. Douching with normal saline solution helps clean the cavity without causing a change in the vaginal flora.

Intercourse

It is generally accepted that 2 months after the surgery will be enough for sufficient healing for “reasonable” intercourse. Discharge and/or blood after intercourse is a sign of inner lining break and should be protected (see “discharge”).

Personal hygiene

Patients learn how to care for themselves at the Asclépiade recovery center. Our trained staff show every step of the way how to dilate, douche ,take care of incision lines .Patients should bathe twice a day and douche every day for two months .After that they can go back to one bath a day and stop douching.

Hair removal

Three months should elapse before any hair removal is done near the surgical site.

Sports

In general patients can start light sport activities after 6 weeks and increase very slowly the intensity.

Orgasm

The onset of orgasm vary tremendously. Some rare patients will experience their first orgasm the second week after their surgery. Others will have to wait two years. An orgasm can be accompanied with ejaculation. In general there is a decrease in sexual drive and libido for a few months after surgery. For a good part of patients sex is not a priority.

Examination by P.C.Physician

Vaginal canal

There is no need to examine the vaginal canal during the first year if there is no discharge or bleeding. At one year postop a visual examination of the cavity can be done to verify the integrity of the inner lining. Hair can be found inside on occasions and can be pulled. Sometimes they fall and accumulate inside at he dome. If in great numbers they will need to be cauterized. CO2 laser is never an option in the cavity.

Prostate

It should be examined through the vagina and it will be found at the antero-inferior portion of the vaginal canal.

Recto-vaginal fistula

A RV fistula can occur after S.R.S. in one patient in 400.It will show up during the first 6 weeks after surgery. The first symptoms will be gas expulsion through the vagina and gas through the anal canal will no longer be. Feces and/or fecal material will be found on the dilator or exiting through the vagina. The patient will be apyretic and will not present with pain. A definitive diagnosis is crucial and should be confirmed without any doubt by a visual examination and confirmed and localized by X-Ray .The patient surgeon needs to be advised and should participate in the investigation and care. In principle, care for a fistula starts quickly after confirmation by stopping the dilation regimen, fistula repair after 6 months and vagina reconstruction after 12 months. In general colostomies are unnecessary and should be kept as a treatment of last resort.

Protracted pain

Pain is usually well controlled with infrequent narcotics and anti-inflammatory during the second and third week postop. Beyond that protracted pain is caused by unhealed raw areas at the entrance of the vagina which can be helped with topical lidocaine gel. If there is no sign of raw areas and the pain is intense ,a deep infection can explain the symptoms .Infection and necrosis of the corpus cavernosum stump is possible. Enzymes rich pus can cause the irritation .A culture and wide spectrum antibiotics should be prescribed.

CT-SCAN anomaly

Rarely patients will have an investigation and a CT-SCAN is done .The alarming response from the radiologist can be describing an unidentified mass above the pubic bone with or without a loculation of fluid. It can be interpreted as a tumor ,cyst or abscess. It is, in reality ,the folded neurovascular pedicle of the clitoris(Buck’s fascia, blood vessels and nerves)! It does not explain a fever in a patient, It should NOT be explored surgically needless to say.

Since everyone is asking questions from everywhere, I decided to write an article to save time. I describe the procedure I followed to get my approval of the RAMQ. This article is for information only and has no legal value: it is my opinion.

Well, before I explain my path, I remember the criteria for eligibility for a  sex reassignment surgery. I am not talking about money I talking about the criteria that apply before the surgeon operates. My surgeon is Dr. Pierre Brassard. You can find on its website, the eligibility criteria. I also refer you to the World Professional Association for Transgender Health, which publishes a document “WPATH Standards of Care.” You will find on page 20 a list of criteria they recommend:

XII. Genital Surgery

Eligibility Criteria. These minimum eligibility criteria for various genital surgeries equally

apply to biologic males and females seeking genital surgery. They are:

1. Legal age of majority in the patient’s nation;
2. Usually 12 months of continuous hormonal therapy for those without a medical;
3. 12 months of successful continuous full time real-life experience. Periods of returning to the original gender may indicate ambivalence about proceeding and generally should not be used to fulfill this criterion;
4. If required by the mental health professional, regular responsible participation in psychotherapy throughout the real-life experience at a frequency determined jointly by the patient and the mental health professional. Psychotherapy per se is not an absolute eligibility criterion for surgery;
5. Demonstrable knowledge of the cost, required lengths of hospitalizations, likely complications, and post surgical rehabilitation requirements of various surgical approaches;
6. Awareness of different competent surgeons.

Readiness Criteria. The readiness criteria include:

1. Demonstrable progress in consolidating one’s gender identity;
2. Demonstrable progress in dealing with work, family, and interpersonal issues resulting in a significantly better state of mental health; this implies satisfactory control of problems such as sociopathy, substance abuse, psychosis, suicidality, for instance).

I remain you that all these criteria must all be met to access to a sex reassignment surgery. So for me, I had, in-hand:

• More than one year of hormone therapy with a letter signed by my doctor endocrinologist Dr. Jean-Hugues Brossard, dated November 2008 with a August 2009 record from my pharmacy indicating that the hormone therapy is still ongoing.
• A report of my sex therapist / psychotherapist Gilberte Talbot who followed me for over a year in Psychotherapy.
• A second letter from Dr. Michel Campbell, who supports the recommendation of my sex reassignment surgery proposed by Mrs Talbot.
• Today, I do not have a full year of real life test but in a month it will be true and my surgery is scheduled for February 9. So pretty after the completion of my first year.

Several aspects are evaluated in these two reports and they cover the criteria of wpath and Dr. Brassard.

So once I got all these documents, I simply presented in the offices of Dr. Brassard located 995 De Salaberry with these documents. They look at them and they have been able to book a surgery date. From that moment, I had 2 choices: 1 – Assume the cost of surgery, the hospital stay and house of convalescent (Asclepiade) or 2 – Make an application to RAMQ for costs coverage by the public health system. Without a doubt, my choice was the second one.

To do so, Suzanne Dugré from the clinic of Dr. Brassard, took copies of my documents and send a request to the CHUM to cover the costs of my surgery. Three weeks later, I received a message from her confirming the coverage of costs by public health system. A huge news for me.

As you probably know, the cost of these surgeries had always been covered by the RAMQ, but it was necessary that this surgery is performed in a public health system such as the Czech Republic or Thailand. It was also required that surgery is prescribed by a physician affiliated with the RAMQ with a license number. For several years the only physician who were prescribing the surgery was Dr. Pierre Assalian from the Montreal General Hospital.

But there were some cases where a family physician had prescribed a sex reassignment surgery and the RAMQ had agreed to cover the surgery cost outside the province in a public health system.

Since the beginning of this year, easing of the law on public-private partnership, allowing public hospitals to do business with a private hospital. Thus, public funds in health remain among us now and create jobs in Quebec.

So for those who are interested in doing a similar path, make an appointment with your psychologist in this objective. Take your time, it takes several meetings before receiving the letters. Moreover, we need two letter, do not hurry it may be long. So, start immediately!

I invite you to make sure that the letter from your therapist will be accepted. Not all psychologists, sexologists, or psychiatrists are expert in gender identity. So check before being disappointed!

If you have any questions, you can contact me directly or the clinic of Dr. Brassard.

PROCEDURE DESCRIPTION :

The technique used is the one step penile inversion.  It is done under general or spinal anaesthesia as an inpatient in the hospital.  The duration is 2 ½ hours.  The scrotal skin is removed along with the testicles.  The neoclitoris is fashioned from the tip of the penis (glans) keeping its blood and nerve supply (neurovascular island flap).

The labia majora are formed with some of the penis skin, the hood and the labia minora with urethral mucosa and penis skin.

The space for the vagina is dissected behind the meatus (urinary tube) between the bladder and the rectum.  The penis skin is inverted to line the vagina and the thinned scrotal skin graft is sutured to the end of the penis skin tube.  Hair roots on the scrotal skin graft are destroyed with the cauthery.  A urinary catheter is put into the bladder, a packing of cotton covered with a condom is put inside the vagina.  The prostate is not removed.

Skin grafts are occasionally necessary.  One location for these can be the inner posterior thigh.  A split thickness graft is taken and leaves a discolorated area of skin when healed.  This issue will be discussed with your surgeon preoperatively.

INTENDED RESULTS :

A natural appearing female genital (vulva and vagina) with adequate depth for vaginal intercourse and normal sensation.

RECUPERATION AND HEALING :

Patients will need to be in Montreal for a 14 day period.  Two or three days are spent at the residence preoperatively, two days at the hospital and five to six days postoperatively at the residence.  You should plan to stay off work for 4 to 6 weeks.

The evening of the following day of your surgery, you will be moved out of bed and encouraged to sit in a chair for a while or take a few steps.  The morning after, walking is strongly encouraged.

RISKS :

The specific risks and the suitability of this procedure for a given individual can be determined only at the time of consultation.  All surgical procedures have some degrees of risk.  Minor complications that do not affect the outcome occur occasionally.  Major complications are unusual.  Please refer to the « Risks for Vaginoplasty» for more detailed information.

OTHER PROCEDURE :

Breast augmentation, Adam’s apple shaving or other cosmetic procedures of reasonable duration can be done at the same time.

Secondary cosmetic improvements to the vulva are generally not required.  Occasionally, patients may chose to have a revision to enhance the genital details.

PROCEDURE DESCRIPTION :

Phallic construction is done by two surgical teams that are working simultaneously.  The forearm skin is harvested and used to make the urethra, the glans and the penile shaft.  You will have a scar of 15 to 17 cm by 13 to 15 cm on your forearm. The skin of the two labia majora is moved posteriorly and united in the center to make the scrotum.  A skin graft is taken from the thigh and used to cover the donor site at the forearm.  The nerves of the clitoris are used for sensibility of the constructed phallus.  The vaginal cavity and clitoris are removed.  We are enclosing diagrams describing the technique.

A second and third operative procedure are necessary to put testicle implants and a penile implant (erection).  This surgical procedure is done when protective sensibility is present to the penile shaft, nine (9) to twelve (12) months after phallic construction.

INTENDED RESULTS :

A male genital scrotum and penis of adequate size for intercourse and urination.

RECUPERATION AND HEALING :

Patients will need to be in Montreal for a 23 day period.  Two  days are spent at the residence preoperatively, four to five days at the hospital and 14 to 16 days postoperatively at the residence.  You should plan to stay off work for 6 to 8 weeks.

The morning of the second  day of your surgery, you will be moved out of bed and encouraged to sit in a chair for a while or take a few steps.  Walking is strongly encouraged thereafter.

RISKS :

The specific risks and the suitability of this procedure for a given individual can be determined only at the time of consultation.  All surgical procedures have some degrees of risk.  Minor complications that do not affect the outcome occur occasionnally.  Major complications are unusual.  Please refer to the « Risks for Phalloplasty» for more detailed information.

OTHER PROCEDURE :

Other surgeries cannot be done at the time of a phalloplasty.  Sometimes minor procedures can be undertaken 10 days after the phalloplasty under local anesthesia.  This has to be determined in advance.

Here it the information send to patient in the USA who looks for a MTF Sex Reassignement Surgery (SRS):

We are pleased to send you a detailed information package on gender reassignment surgery male to female.
Enclosed you will find: letter of introduction
Information document on male to female GRS
Medical history document
GRS in Montreal brochure
Our modern and safe hospital care is personalized and our staff has a high
experience with transgender patients. Low overhead combined to favorable exchange rate are responsible for
the low cost of procedures with GRS in Montreal.
In choosing Montreal you do not settle for less. On the contrary you pay for state of the art procedures and
unsurpassed results based on a vast experience with transgender surgery. Also with the residence, you
benefit from a unique care concept which is not available anywhere else in the world.
We and our staff would like to thank you for your interest in our surgical services and please do not hesitate to
contact us if you need anymore information.

INFORMATION DOCUMENT ON MALE TO FEMALE GRS

CRITERIA FOR ELIGIBILITY:
To be eligible for Gender reassignment surgery, one must, first of all, answer to the criteria of the Harry
Benjamin International Gender Dysphoria Association’s standards of care for gender identity disorders (sixth
version).

1. Usually 12 months of continuous hormonal therapy
2. Successful continuous real life experience for 12 months
3. Two letters of recommendations for genital surgery and one letter for breast surgery

If the first letter is from a person with a master’s degree, the second letter should be from a psychiatrist or a
Ph.D. clinical psychologist, who can be expected to adequately evaluate co-morbid psychiatric conditions. If
the first letter is from the patient’s psychotherapist, the second letter should be from a person who has only
played an evaluative role for the patient. Each letter, however, is expected to cover the same topics. At least
one of the letters should be an extensive report. The second letter writer, having read the first letter, may
choose to offer a briefer summary and an agreement with the recommendation.

The Mental Health Professional’s Documentation Letters for Hormone Therapy or Surgery should
succinctly specify:

1. The patient’s general identifying characteristics :
2. The initial and evolving gender, sexual, and other psychiatric diagnoses;
3. The duration of their professional relationship including the type of psychotherapy or evaluation that the patient underwent;
4. The eligibility criteria that have been met and the mental health professional’s rationale for hormone therapy or surgery;
5. The degree to which the patient has followed the Standards of Care to date and the likelihood of future compliance;
6. Whether the author of the report is part of a gender team;
7. That the sender welcomes a phone call to verify the fact that the mental health professional actually wrote the letter as described in this document.

SETTING A DATE FOR SURGERY:
The medical history document and the two recommendation letters for G.R.S. must be well detailed and must
arrive at our office before a date can be set for the surgery. Also, we wish a report from the doctor who is
supervising the hormonal therapy as to the type of hormones being administered, the dosage and the duration
of the treatment.

PRE OPERATIVE CONSULTATION

It is preferable to meet your surgeon prior surgery during a preoperative consultation. However, if one lives
very far from Montreal, it is possible to meet a few days prior to surgery. If the latter is the case, the patient’s
file must be complete: the two recommendations, the laboratory reports and the medical history document and
the physician letter on hormonal therapy, must be at our office before the visit. If a document is missing, the
surgery could be cancelled.

PRE OPERATIVE ANALYSIS: LABORATORY REPORTS :

As this is a major surgical procedure, under general anesthesia, the patient must pass the following tests about
two months before the date of the surgery and the results of these exams must be sent to our office one month
prior to the date set for the surgery. Without these test results, there will be no surgery. PLEASE WAIT TO
HAVE A DATE OF SURGERY BEFORE HAVING YOUR PRE-OPERATIVE TESTS DONE. Tests that were
done more than 3 months prior the surgery date will be considered unusable and will have to be redone.
Following is a list of the obligatory tests:

• CBC (complete blood count)
• BUN (blood urea nitrogen)
• Glucosis (blood sugar)
• Urine analysis
• E.C.G. (over 40 years of age)
• H.I.V. test

Unfortunately we are sorry to inform our prospective patients that insulino-dependant diabetic patients will
not be accepted for surgery.
This systemic disease is for our Center a contraindication for major procedures because of the absence of
competent consultants in the field of endocrinology.
GRS insulino-dependant diabetic patients should be performed in major hospitals where all the internal
medicine expertise is available.
Thank you for your comprehension.

HOSPITALIZATION

Normally, the surgery is performed on a Monday or a Tuesday. You enter the hospital around 7:00 p.m. the
day before. You leave the hospital on the third or fourth post operative day. The vaginal stent and the urinary
catheter are removed on the sixth, seventh day. You must remain another 2 to 3 days in our residence home
to master your vaginal dilations.

ANAESTHESIA FOR YOUR SURGERY

Gender reassignment surgery (vaginoplasty) can be done under general anaesthesia or regional spinal
anaesthesia. Both work equally well but patients like having less side effects with the spinal. However, there
are some contraindications. The anaesthesiologist will decide if you are a good candidate for a spinal.
General anaesthesia is always used if you have another surgery at the time of your vaginoplasty.

SURGICAL TECHNIQUE-ONE STEP-PENILE INVERSION

We perform the penile skin inversion technique. The penile skin is inverted to create the vagina (vaginoplasty).
When the penis is too short, we use the excess skin from the scrotum (graft) to have a sufficient amount of
skin for the vaginoplasty. The clitoris is made from an innervated island of the glans (sensate clitoris). In fact,
part of the glans is pedicled to the dorsal nerves and vessels of the penis (island flap) shaped to construct the
clitoris. The labia minoras are made with mucosa from the urethra and penile skin during the same procedure
(one step procedure).

ELECTROLYSIS:

Hair removal on external genitals before male to female reassignment surgery is debatable.
Hair bearing skin on the penis shaft base with the one step technique stays outside on the neo vulva. The skin
that will become the internal living of the new female genital is the rest of the penis skin, scrotal skin and a
small « perineal flap » (a one square inch of skin that is located one side above the anal margin on the midline)
If you want a perfect hairfree vagina you need to be sure that no regrowth of hair has occured on the area for at
least one year after you have finished electrolysis on laser. Even then this does not garant that no hair will ever
grow.
The hair roots are either killed or weakened by electrolysis or laser. Those only weakered regrow. During
surgery hair roots are killed with the cauthery on the scrotal skin that is used as a graft ( not on the « perineal
flap » ) During surgery the hair roots that were weakered are less visible because they are much smaller than
those found untreated areas and could be missed by the surgeon and regrow later. For this reason, in our
experience expeditive laser or electrolysis treatments are worse than not having hair removal at all. In fact, we
can get most hair roots during surgery if they were not weakened. Regrowth after our surgery is possible but
very sparse.
If you want no regrowth at all you will have to face hours of painstaking hair removal and a one year
nonegrowth period.
At this time we do not feel that hair removal is indicated.

COST

Please contact us for pricing.

YOUR STAY IN MONTREAL

Your stay in Montreal should be between 12 to 14 days : between 2 and 4 days before the operation, 4 days in
hospital and finally 5 to 6 days after leaving the hospital.
It will be possible to have companying with you at the residence.

To make your recovery more pleasant and secure, we have a convalescence residence for pre and postoperative
period. They supply care, lodging and meals. Do not forget that post-operatively you will need help
and it is the only place where you will receive adequate, professional care. The address of the residence
care is 908 Gouin ouest Montreal, Qc H3L 1K8 Phone number is: 514 333 1572.
Three weeks before your surgery, we ask you to confirm with the office if you are arriving by plane,
train or auto, the date of your arrival, the time of arrival, airline or carrier, flight or train number. Please
note if you have a criminal record, you may buy a visa at your arrival at the airport to be allowed to stay
in Canada (around 100$ u.s.). When we will confirm your date of surgery, we will send you a form to complete
concerning your travel information. At the Customs, be sure to have a passport. Since January 23rd
2007, you need a passport to return to United states.

ADDITIONAL SURGERIES

If you wish to have an additional surgery done at the same time of your GRS., (e.g. breast implants, Adam’s
apple shave, nose, eyelids surgery etc.) you will pay a little less for the surgery.
If you wish further information, you may write, e-mail or call our staff.
Yours truly,
For :

PIERRE BRASSARD, M.D., F.R.C.S.(C)
P.S.: It is absolutely forbidden to smoke at the hospital.