SURGERY for Transsexual People (M2F)

This section will discuss some of the surgical procedures commonly undertaken by those who are diagnosed as "transsexuals." Some of these procedures were adapted from similar surgeries performed on intersexed individuals.

SRS means "Sex Reassignment Sugery," which is the more widely accepted terminology for the so-called "Sex Change Operation" in the United States. Some people prefer to call it "Sex Reconstructive Surgery," especially if it is being done on an intersexed patient.

GRS means "Gender Reassignment Surgery," which is the more commonly used terminology for so-called "Sex Change Operations" outside the United States. Some people prefer to say it stands for "Genital Reconstructive Surgery" instead. Another new term for this has also surfaced: Gender Confirmation Surgery, but is not yet in wide usage.

Either term is acceptable and correct.

Facial Feminization Surgery (FFS)

Several surgically correctable differences which will make a dramatic difference in the perceived gender can often be identified to the benefit of a male-to-female transsexual. Collectively these are referred to as "Facial Feminization Surgery" (FFS), which is currently the most widely used terminology. However, some transsexual people prefer to call these procedures "Facial Sex Reassignment Surgery" (FSRS) instead, as a way to indicate the level of importance for many Male-to-Female transsexual people in their social presentation as going far beyond mere "feminization." Others point out that when a woman has a nose job, or work done on her cheeks or jawline, or even an eyebrow or face lift (essentially many of these same procedures) it is never referred to as "feminization surgery," but is, instead, simply called "cosmetic surgery." Which makes sense given that these procedures are usually performed by cosmetic or reconstructive surgeons. Whatever you choose to call these procedures, they may be subdivided into the following:

Forehead
Forehead recontouring involves rounding the forehead to approximate a female shape, often by shaving bone from the brow of filling in flat areas to round them out. Reducing brow ridges, if excessive, can considerably improve the feminine appearance.

Common task include:

Scalp reduction: involves advancing forward the scalp between 1.0 cm and 2.5 cm to correct for the receding masculine pattern hairline and to approximate, when possible, a more feminine 'oval' pattern hairline.

SMAS/platysma (deep plane) rhytidectomy: involves lifting the cheeks, jowls, jawline, and neck and their underlying muscles.

Forehead contouring: involves shaving the brow bossing and, if necessary, contouring via shaving across the forehead.

Forehead augmentation: involves the use of 2, 3, or 4 implants (Gore-Tex Subcutaneous Augmentation Material).

Nasal Surgery (Rhinoplasty)
The nose is the most prominent feature of the face. Many transsexual women find a "nose job" makes one of the most remarkable improvements in their female facial appearance. It is the most common procedure after breast augmentation.

Nasal surgery or rhinoplasty alters the appearance of the nose by shaping and repositioning the nasal bones and trimming the bone and cartilage as needed to create the desired appearance.

Septal Surgery - The strip of cartilage which separates the two sides of the nose is called the septum. It is sometimes bent and interferes with breathing; if so, it may need to be straightened. If it is too long, it is often shortened.

Shaping the Profile - Many women complain of a hump on the bridge (dorsum) of the nose. This is usually made of both bone and cartilage. It is removed with scissors or a saw. When the nose is flat, the profile may be augmented with grafts of bone or cartilage.

Refining the Tip - If the tip of the nose is large or boxy, much of the tip cartilage may be removed or reshaped to refine the shape.

Narrowing the Nasal Bones - If the bridge of the nose is wide, the surgeon will narrow it by fracturing the bone on each side and moving it closer to the centre.

Reducing Nostril Flare - If the nostrils are flared, they may be reduced by removing a small wedge of tissue from the base of the nose.

Cheeks
Cheek implants, also called submalar implants, can make the face look less flat, which can enhance its feminine appearance. Like any implant, there is a danger of rejection.

Common tasks include:

Cheekbone reduction: involves an intra-oral incision which requires an extended recovery period (with severe facial swelling/bruising for about 10 days).

Cheekbone augmentation: involves an intra-oral incision to augmenting the bone with a hard silicone implant.

Lip contouring: involves lifting the upper lip via a shallow 'v' incision below the nose or by an incision inside the lip. If necessary, the lower lip can be made fuller via an incision inside the lip.

Chin and Jaw
The chin is an extremely important area in gender recognition. Although the potential benefits can be great, the difficulties involved in re-shaping a "robust" lower jaw sufficiently to make a significant improvement in overall facial feminization prevents this being a very common surgery.

Possible tasks include:

Jaw reduction: involves a 1.0cm extra-oral incision under the jaw line to cut the bone (on average, by 1.0cm depth) and thus reduce the sharp angle of the back corner of the jaw where it rises up to the ear.

Alternatively, an intra-oral incision can shave (but not cut) the bone. Although this technique prevents external scaring, it is less effective, has more risk of infections, and requires an extended recovery period due to severe facial swelling/bruising.

Chin reduction: involves an intra-oral incision to shorten and narrow the chin (if necessary, including contouring with a hard silicone implant). The technique involves: (1) shaving the bone; (2) cutting the bone; or (3) sectioning out the mid-section of chin and joining the upper and lower sections via steel screws.

Sliding genioplasty: involves an intra-oral incision and sliding forward or backward the lower section of chin (if necessary, including contouring with a hard silicone implant).

Chin augmentation: involves an intra-oral incision to advance a short or/and receding chin with a hard silicone implant.

Traceal Shave
A trachea shave is a common procedure undertaken in order to reduce the woman's "Adams's Apple" to more normal female proportions. Many women DO have something of an "Adam's Apple," but women rarely have a pronounced one, as many men do. This procedure only removes the tissue that causes the "lump" on the throat, it does absolutely NOTHING to change the pitch of a person's voice!

COST:

Costs for these procedures vary wildly from a couple thousand dollars to hundreds of thousands of dollars depending on the surgeon and how much surgical alteration is required or desired. "Name" surgeons usually charge more, but if they know what they are doing it may be worth the extra cost and wait to see them. These procedures often involve more "reconstructive" type work with the facial bones that is beyond the technical skills of many cosmetic surgeons who do little more than face-lifts or nose jobs. If you are contemplating FFS, you may wish to read the well documented surgical experiences of Sally, Nicole Hamilton, or Kate (in Belgium) with before and after photos.

Surgeons providing FFS:

Douglas K. Ousterhout, MD, DDS - Better known as "Dr. O" (sounds like a James Bond character doesn't he?). He is probably the best known and best regarded FFS surgeon providing complete cosmetic services. He has written a very good article on the subject reprinted on Dr. Becky's website. Contact info: 45 Castro Street, Suite 150, San Francisco, California 94114. Phone: (415) 626-2888. emal: ousterht@cris.com

Dr. J.L. Hoeyberghs, Wellness Kliniek, Grotestraat 42, 3600 GENK, Belgium Phone: 0032 89 32 95 00. - performs tracheal shaves.

Dr. M.F. Noorman van der Dussen Contact info: Monica vzw, Campus Eeuwfeestkliniek, Harmoniestraat 68, 2018 Antwerpen, Belgium. Phone: 00-32-(0)3-237 61 05 or London Centre for Aesthetic Surgery, 15 Harley Street, London W1N 1DA, United Kingdom. Phone: 0044-20-7636-4272. - provides complete FFS services.

Dr. Pierre Brassard, Montreal Canada - performs tracheal shaves

Dr. Yvon Menard, Montreal, Canada - performs rhinoplasty and tracheal shaves.

Dr. Jean Abitbol, Paris, France E-mail: abitbolj@cybercable.fr - performs tracheal shaves.

Stefan Gress, Dublin, Ireland (no contact info) - performs Brow lifts, Face lifts, and Liposuction.

Dr. A.G. Becking, VU medisch centrum, De Boelelaan 1117, Postbus 7057, 1007 MB, Amsterdam, Netherlands. Phone: 00-31-(0)20 - 444 1150. - performs three kinds of forehead contouring.

Dr. deVries, Lucas Ziekenhuis, K.N.O.-heelkunde, Jan Tooropstraat 164, 1061 AE, Amsterdam, Netherlands. Phone: 020 5108894 - performs tracheal shaves.

Professor (Dr.) Mahieu, Academish Ziekenhuis Vrije Universiteit, Department of Otolaryngology/Head and Neck Surgery, P.O.Box 7057, 1007MB Amsterdam, Netherlands. Phone: 0031-20-4443687. - performs tracheal shaves.

Dr. Chettawut Tulayaphanich, 1529/4 Onnut 31 Sukumvit 77 Rd. Bangkok 10250, Thailand. Phone: (662)742-0845 E-mail: info@chet-plasticsurgery.com

Sanguan Kunaporn, Phuket Plastic Surgery Center, 20/44 Mae Luan Road, Phuket 83000, Thailand. Phone : +66 76 221631. E-mail: info@phuket-plasticsurgery.com - Eyebrow lift, Lower Blepharoplasty, SMAS/Platysma Rhytidectomy, Upper Blepharoplasty.

Dr. Pichet Rodcharoen MD., FRCS (T) Head, Division of Plastic surgery Rajavithi Hospital
School of Medicine, Rangsit University, 519 Suthisan Rd., Huaikwang District Bangkok 10310
Thailand. Phone: +662-690-8080. E-mail: pichet@bangkokplasticsurgery.com - performs full FFS services.

Dr. Preecha Tiewtranon, M.D., 33 Sukhumvit 3 (Soi Nana Nua), Wattana, Bangkok 10110, Thailand. Phone: +662 641-5120/5121/5122 - provides complete FFS services.

Suporn Watamusakul, MD, Thailand Phone: +66 9 8051057 E-mail: inquiry@srs-thailand.com - provides complete FFS services.

Mr. A.D. Cheesman FRCS, Royal National Throat, Nose & Ear Hospital, Grays Inn Road,
London WC1X 8DA, United Kingdom. Phone: 020 7915 1434 - performs tracheal shaves.

George Murty, Central Leicestershire,United Kingdom, Phone: 0116 238 8140. - performs tracheal shaves.

Mr. Brian Musgrove, Maxillofacial Unit, FRCS [NHS], Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL United Kingdom. Phone: 0161-2768639 E-mail: musgrove@central.cmht.nwest.nhs.uk. - Performs bilateral osteotomy, Forehead Contouring, Jaw Reduction (internal incision), mandibular flaring reduction, Otoplasty, Rhinoplasty, Scalp advancement, Sliding Genioplasty.

Toby R. Meltzer, M.D. Portland, Oregon and Scottsdale, Arizona USA. Performs Cheek implants, Eyebrow lift, Face Lift, Forehead Contouring, Jaw Reduction (internal incision), Lip augmentation, Lip lift, Lower Blepharoplasty, Thyroid Cartilage Reduction, Upper Blepharoplasty.

Gary Alter, Los Angeles, California.

Breast Augmentation Surgery

Some studies have indicated that 50-60% of all transsexual women do not achieve satisfactory breast growth by hormone therapy alone. A Dutch study found that two-thirds of the transsexual women they surveyed had undergone breast augmentation more than once trying to achieve the desired feminine body contours.

Transsexual women often have special needs or desires concerning breast augmentation that are not addressed by mainstream cosmetic surgeons, and those that do often charge excessively for their expertise in dealing with transsexual women.

Breast augmentation, technically known as "augmentation mammoplasty," is a surgical procedure to enhance the size and shape of a woman's breast by inserting an implant behind each breast. The usual goal of breast augmentation is to achieve the most beautiful and natural looking breasts possible - although a natural look is not always desired by some women. To create an aesthetic and symmetrically balanced breast using implants to enhance them is not an easy task.

For best results in a transsexual woman, augmentation should not be undertaken before maximum breast development from hormone use has been achieved, the more breast tissue available the better. Rushing into breast augmentation at the start of a transition and hormone treatment is probably a considerable mistake. Breast implants that have only skin coverage are likely to appear artificially round, with the edges of the implant plainly showing. As a rule of thumb, if the breast size is still unsatisfactory after two years of hormone therapy then augmentation may become appropriate.

Breast augmentation is a very well established and straightforward procedure that is capable of producing excellent results - its certainly no secret that many top models and actresses have had breast augmentation! In some instances excessively large implants or rather poor quality surgery make augmentation obvious. But for many girls, with the right choice and size of implant and good quality surgery, an augmented breast can appear totally natural - indistinguishable from a normal breast in or out of clothing.

Factors to Consider

Every woman has a different body shape which should influence the contours of the enhanced breast. Different breasts and body contours will determine the size and style of the implant and in some cases the location of the incision as well.

Slope - Aside from the size issue, a beautiful breast has several components. First, it is desirable to have a gentle slope that extends from just below the clavicle to the peak of the breast at the nipple position. A bulge in that region is a telltale sign of an implant and a "scooped-out" area probably means the breasts are too saggy. A smooth, gentle line should be present.

Nipple Position - Second, the nipple position should be in the region of the centre of the breast mound. The nipple should tilt slightly outward and upward. Then the line of the breast should dip in a gentle arc from the nipple to the breast fold.

Breast Width - Breast width is an especially important dimension, because it determines how much cleavage there is between the breasts. Breast width also determines the outside curve of the breasts, which helps balance the hips and narrow the waist.

Cleavage - Cleavage is always desirable, and when the breast is viewed from the front in silhouette or from the back, there should be a gentle suggestion of fullness in the midline and laterally.

Size - Once all these components are considered, the overall breast size becomes the final factor. The optimum breast size is determined by measuring and studying the woman's body shape and bone structure. A good surgeon will ask the woman to pick pictures or photographs of breasts that she feels are desirable.

Factors that increase the liklihood people will suspect they are implants:

• Thinner woman with with thinner fat layer
• Smaller pre-operative breast size
• Larger implant size
• Textured-surface implants (increases degree of "traction ripppling")
• Saline rather than silicone gel fill
• Inadequate volume of saline inside saline implant

Factors that decrease the liklihood people will suspect they are implants:

• Heavier patients with thicker fat layer
• Larger pre-operative breast size
• Smaller implant size
• Silicone rather than saline fill
• Smooth-surface implants
• Optimum volume of saline inside

PROCEDURE

The procedure for breast augmentation is done differently by individual surgeons. In general they follow the following process:

1. The patient and surgeon agree on the desired size, shape and look of the augmented breast.
   
2. The type (smooth or textured), shape (round or anatomical) and size (measured in cc of volume) of implant is selected. The implant may contain saline, silicone gel, or some other filler.
   
3. The incision site is determined; this can be nipple (areolar), armpit (transaxillary), under the breast (inframammary) or navel (transumbilical).
   
4. The site of implant placement is decided; this can be above the muscle (subglandular) or below the muscle (submuscular).

There are significant risks to undergoing breast augmentation, not just from the surgery itself but from the type of material from which the implant is made and how it may interfere with future detection of breast cancer. For a more complete, in-depth article on breast augmentation please visit Annie Richard's web site (from which I hope she doesn't mind I copied some of this information).

COST:

Again, the cost for this procedure varies from a couple thousand dollars to as much as a cosmetic surgeon can get away with charging someone. Definitely a procedure that requires the patient shop around a bit and DEFINITELY check out the educational background and experience of the surgeon and demand references from satisfied clients who have undergone the same procedures.

Surgeons offering breast augmentation:

Literally too numerous to list here. Virtually every cosmetic surgeon performs breast augmentations, but relatively few - it seems - have experience dealing with transsexual women.

Bilateral Orchiectomy / Orchidectomy (i.e., Castration)

Bilateral Orchiectomy (called "Orchidectomy" in British English) means the removal of both testes, i.e. "castration." It is a serious alternative to antiandrogen hormone therapy for androgen suppression in preoperative transsexual women, and is now widely regarded as a useful precursor to SRS in many cases. However, many SRS surgeons prefer to do this themselves as part of the reassignment operation, and charge for it whether they have to do it or not under the assumption it may not have been done the way they wanted and they'll spend time "fixing another surgeon's mistake."

Because the testes are conveniently located external to the body cavity, they are relatively easy to remove and an Orchiectomy is considered to be a quite minor operation. Usually a small incision is made in the scrotum, the sac that contains the testicles. The testicles are detached from blood vessels and the vas deferens (the tube that carries sperm to the prostate before ejaculation), and the sac is sewn back up. Orchiectomy can be performed as an outpatient procedure under local anaesthesia, or under general anaesthesia with an overnight stay in hospital.

Physical effects of an Orchiectomy:

• Diminished libido (sexual desire)
• Erectile dysfunction (inability to achieve or maintain an erection adequate for intercourse)
• Hot flashes similar to those experienced by women during menopause. They are characterised by a sudden spread of warmth to the face, neck, and upper torso, usually followed by profuse sweating. Their effects may be controlled with oestrogen and other HRT.
• Weight gain of 10 to 15 pounds (4 to 7kg) is a common occurrence.
• Mood swings are common.
• Depression may occur.
• Fatigue, a feeling of extreme tiredness that may not be alleviated by rest or sleep. This is caused by decreased testosterone production and anemia, a deficiency of red blood cells in the bloodstream.
• Loss of muscle mass with decreased strength or weakness.

Advantages for a Transsexual woman:

Safety - after Orchiectomy the patient is endocrinologically identical to a post-operative SRS patient. Thus allowing hormone therapy dosages to be lowered. This has clear safety advantages especially in patients thought to be at elevated risk of thromboembolic events (i.e."blood clots")

No waiting - the HBIGDA Standards of Care do not cover Orchiectomy. There is no requirement for a person to live "in role" for any time period prior to undergoing a "Orchie." There are many surgeons who will also perform the operation without a psychological consultation. There are no requirements for "letters of recommendation" for the procedure.

Improved feminization - without the activity of testicular produced androgens, estrogen activity throughout the body is unopposed, resulting in faster, more pronounced femininzation.

No reversal of effect - when a transsexual person stops taking hormone therapy medications, they can see a "reversal" of the effects of that therapy. Once a transsexual woman has undergone an Orchiectomy, they will not suffer any reversal effects if they should have to cease hormone therapy for some reason.

Incidental benefits - It is claimed that a bilateral Orchidectomy protects against coronary artery disease, cerebrovascular disease and effectively increases the life span by an average of 5 years.

Psychologcial benefits - transsexual women are usually very pleased with the reduction in "maleness" in their genital area after an Orchiectomy. This can produce a significant improvement in emotional well-being.

Disadvantage to an Orchiectomy:

Risk - no surgical procedure is without risk.

Scrotal atrophy - the tissue is needed for SRS. If there is a long period of time between the Orchiectomy and SRS it may have shrunk too much to provide enough tissue for the SRS surgeon. However prolonged use of hormones alone can also cause scrotal and penile atrophy. Stretching exercises can be applied to limit this effect somewhat.

The following are disadvantages to the transsexual woman who is unsure of transition and wants to keep open the option of reverting to a male existence:

Permenant infertility - Orchidectomy will cause a complete and irreversible loss of sperm production, with permanent sterility. Male sex drive and sexual function can in principle be restored by administration of testosterone. Note: If the patient has been on hormone therapy for any length of time they have more than likely already been rendered permenantly sterile anyway.

COST

A Bilateral Orchidectomy in the USA is available for as little as $1200 when done under local anaesthesia as a day case, going up to about $5000 with general anaesthesia and an overnight stay in hospital. Orchidectomy surgery is also very cost-effective in comparison with long term androgen suppression treatment, whose costs can easily amount to $1000 or more a year, depending on the drugs being taken.

Surgeons who perform Orchiectomies:

Truthfully, there are MANY MANY doctors who will perform this procedure. It's mostly a matter of asking around. One doctor who makes something of a business of it for the Transgender Community is Dr. Felix Spector of Philadelphia, Pennsylvania in the United States.

DIY WARNING

There are several "do-it-yourself methods for Orchiectomy. The following methods are intended ONLY for use on farm animals, but there are Emergency Room reports of people using these on themselves:

• The burdizo is a clamp like device (available at a veterinary or farm supply stores) which fits over the scrotum and when activated snaps together crushing the cords within the scrotum with little damage to the outside. After a few weeks the testes dry up. The technique is virtually blood free, but excruciating pain for a short time.
  
• Elastrators are elastic bands placed around the scrotum and just left there until it falls off, three to four weeks. The bands are very tight and have to be applied with a special tool.

Both these methods are EXTREMELY dangerous! DIY Orchiectomy is foolish and potentially deadly. It is strongly recommended that nobody attempt this at home on themselves or others.

Sex Re-assignment Surgery on Transsexual People

There is some argument over whether or not surgery is "medically necessary" or not. The Harry Benjamin Internationl Gender Dysphoria Association states in it's "Standards of Care" for the treatment of transsexuals that, ". . . .Sex reassignment is not 'experimental,' 'investigational,' 'elective,' 'cosmetic,' or optional in any meaningful sense. It constitutes very effective and appropriate treatment for transsexualism or profound GID." In other words the HBIGDA party line is that such surgery IS "medically necessary."

However, statistically most diagnosed transsexuals do not undergo surgical reassignment. And most insurance companies and National Health programs consider it an "elective, cosmetic" procedure because it can provide only the APPEARANCE of external genitalia without any of the reproductive functionality. Many transsexual people also insist that they do not need to undergo surgical reassignment to feel "complete" in their preferred gender role.

Other reasons transsexual people may not wish to undergo SRS procedures include:

• A medical problem which prevents major surgery.
• A homosexual sexual orientation.
• Lack of money for surgery.
• Fear of the surgery.
• Uncertainty as to the strength of one’s transsexuality and a desire to be able to turn back.
• Pressure from a partner, family or friends.
• Potential loss of earnings after surgery. particlularly if working as a "she-male" sex worker or "female impersonator/Drag performer."

Reasons transsexual people may decide to undergo SRS procedures:

• A need to match the bodies physical sex with a female psychological gender.
• To present a female physical appearance even when nude, and remove fears of visual detection as a "man".
• To enable heterosexual relations with men.
• A strong and sexually exciting desire to have female genitals.
• To remove the masculinizing physical effects and/or urges caused by the testes.
• Concern about long term liver damage due to prolonged use of anti-androgens and high estrogen and progesterone doses.
• Comfort, avoidance of testicular discomfort when wearing tight under-wear/swimwear.
• Pressure from a partner, family or friends.
• As a prerequisite to obtaining proper legal identification in the preferred gender.

Note: These listed reasons mostly pertain to Male-to-Female transsexual people, though some of them also pertain to Female-to-Male gender patients as well.

There is more than one kind of SRS procedure available:

Partial SRS - involves surgical removal of the testes and penis for the construction of, what externally appears to be female genitalia. There is no emphasis placed on vaginal depth, as the external appearance is considered more important. Labiaplasty usually is performed in a followup operation several months after the initial surgery. This is usually done following the "Penile Inversion" technique.

Full SRS - referred to as "Penile Inversion Vaginoplasty" (which is NOT abbreviated "PIV" because that already stands for "Progestin Induced Virilization," which is an intersex condistion). Penile Inversion Vaginoplasty involves the removal of the testes and penis and formation of female appearing external genitalia, and the formation of a neo-vagina with adequate depth for intercourse. Often be followed several months later by a labiaplasty, although some surgeons will perform labiaplasty concurrent with the rest of the operation it is not considered wise because of the increased risk of reducing blood flow that may result in necrosis (tissue death). To better insure result, labiaplasty is usually delayed until a patient has fully healed from the first operation.

Sigmoid Colon Vaginoplasty - This operation was adapted from a procedure performed on intersexed and underdeveloped girls who were born without vaginas. It is not recommended as a primary SRS operation and is usually reserved for patients that could not achieve adequate vaginal depth via Penile Inversion Vaginoplasty. There are much greater risks to undergoing this surgery because the abdominal cavity is entered and the patient must concurrently heal from TWO major operations at the same time. Basically how it differs from Penile Inversion techniques is that a section of the colon is used to construct the neo-vagina. There are some advantages, beyond achievable depth, to this procedure however. The section of colon is "naturally distensible" and does not require the stretching and dilating exercises necessary with Penile Inversion Vaginoplasty. The section of colon also has its own blood supply and is naturally self-lubricating via the production of mucous. Though some patients who have undergone the Sigmoid Vaginoplasty report an over-production of mucous that requires they wear a pad all the time. The American Educational Gender Information Service, Inc. (AEGIS) has issued a safety bulletin concerning this procedure.

Modified SRS - There is also at least one transsexual woman who has undergone a modified SRS in order to keep her testicles (albeit internally). More information on this procedure is available on Anne Lawrence's web site.

COST:

Costs for SRS procedures vary widely from a few thousand dollars to upwards of $20,000 - even up to $100,000 for F2M Phalloplasty! Generally SRS overseas is less expensive than within the United States. However, one must also factor in travel expenditures if seeking SRS overseas. Doctors in Asia tend to be less concerned with checking for "letters of recommendation" from a psychotherapist. Psychotherapy is not prevelent in most of Asia, which does not follow the HBIGDA Standards of Care, so it is a popular destination for those who seek SRS outside of the established medical guidelines in the West. Others go simply because it is less expensive and they get to turn their recovery into a tropical "vacation" or sorts. Those seeking surgery overseas should be aware that many government agencies in the United States will require a notorized letter from their surgeon in order to change legal documents (such as a US Passport or birth certificate). This can be problematic if one undergoes surgery in a country without a notary system. Those seeing foreign doctors should check with various State and Federal agencies ahead of time to find out what documentation they require or deem acceptable.

SURGEONS:

Perfoming both Penile Inversion Vaginoplasty and Sigmoid Colon Vaginoplasty:

Dr. Peter Walker in New Zealand (performs a modified ascending colon technique)

Dr. Sanguan Kunaporn in Phuket, Thailand

Dr. Preecha Tiewtranon and Dr.Prakob Thongphiew in Bangkok, Thailand

Dr.Chettawut Tulayaphanich also in Bangkok, Thailand

Dr. Suporn Watanyusakul in Chonburi, Thailand

Peter Haertsch in Epping, New South Wales, Australia (no web site) Phone no. +61 2 9868-5155, FAX +61 2 9868-5360 PO Box 441, Epping NSW Australia 2121

Dr. Gary Alter, Los Angeles, California, USA

The following doctors appear to perform only the Penile Inversion technique:

Yvon Menard and Pierre Brassard in Montreal, Canada.

Dr. Marci Bowers in Trinidad, Colorado. 328 Bonaventure St, Suite 5, Trinidad, CO, 81082. Phone: 719-846-4433. (note: Dr. Bowers took over the SRS practice of Dr. Stanley Biber).

Dr. Micheal Brownstein of San Francisco, California, USA

Oliver M. Fenton in Leeds, UK (no website) Phone: +0148 453 3131 at Huddersfield Nuffield. Methley Park Hosp, Methley lane, Methley,
Leeds LS26 9HG 0197 751 8518

Dr. Toby Meltzer in Portland, Orecgon and Scottsdale, Arizona, USA

Michael Royle in East Sussex, UK (no website) The Hove Nuffield Hospital, 55 New Church Road, Hove, East Sussex BN3 4BG England
TELELPHONE: 0127 3720217, FAX : 0127 322 0919

Michael Seghers of Brussels, Belgium (no website). Avenue de Broqueville 60 1200 Brussels, Belgium Office: +32-2/ 770.01.08 Fax: +32-2/ 770.01.08
Department in hospital: +32-2/ 739.84.05

Timothy Terry in Central Leicestershire, UK (no website) Phone no. +0116 265 2665

Dr.Eugene Schrang or Neenah, Wisconsin, USA