Recently a member of the everybodysgood.com team had the honor of interviewing Kathy L. Rumer, D.O. She is a board certified plastic and reconstructive surgeon who specializes in cosmetic and reconstructive surgery for gender variant individuals.  She is the founder of Delaware Valley Aesthetics, where she works with other specialists to provide the best possible healthcare for her patients.  She is on staff at a number of the best hospitals in the Philadelphia area and has been named a Main Line “TOP DOC” in 2008, 2009, 2010. She was also named a Philadelphia Magazine “TOP DOC” for 2011. She also serves as a fellowship site director for the Philadelphia College of Osteopathic Medicine, one of the only residency programs that trains surgeons in the art of gender variant cosmetic and reconstructive surgery. Finally, she is an active member of WPATH and has served as an advocate for transgender individuals at a local and national level.

Q: What are the top surgeries for FTM (female to male) transgender individuals?

A: For top surgeries I offer a couple different options.
For very small breasts (size A or less) I can perform liposuction of the chest wall alone or with a very small amount of breast tissue removed from an crescent-shaped incision made underneath the areola.
Another  option is keyhole surgery (size small B or large A) which is where the breast tissue is removed through an incision made all the way around  the areola and then the tissue is closed with a purse string stitch around the areola.  This can also be combined with liposuction for better chest wall contouring.
The third type of surgery (for breasts larger than a small B) is a double mastectomy with free nipple grafts or double incision with free nipple grafts.  In this procedure the breast tissue is removed through an incision that is made on top of and underneath the breast (double incision) and the nipple is replaced on the chest wall as a skin graft.

All three of these procedures give great results and give the patient a very masculine look.  You can see the results of my surgery on my website www.transphilly.com.

Q: What are the bottom surgeries for FTM (female to male) transgender individuals?

A: For bottom surgeries there are also a few different procedures I recommend.
The first surgery is called a Metoidioplasty. This procedure involves creating a penis by releasing the clitoris that has already been enlarged from testosterone therapy and local tissue or a skin graft is used to create the shaft of the penis.  The size of the penis is based on how large the clitoris gets in response to the testosterone and how much of a release can be gotten, which is typically based on the patient’s genetic makeup.  Everyone responds to testosterone differently. You will still be able to have an orgasm when having sexual intercourse, because the clitoris will still have sensation.
If you are interested in a larger penis I recommend a Phalloplasty. In this procedure a penis is created from a flap of tissue that is taken from the patient’s lower abdomen.  In addition, a Glansplasty can be performed to recreate the appearance of a circumsized penis, or the flap can be left alone to give the appearance of an uncircumsized penis.
I don’t recommend a Urethroplasty (urethral extension or "hook up") with either the metoidioplasty or the phalloplasty, because there is a very high rate of complications after surgery.  These complications can lead to the patient having trouble urinating and can require multiple additional surgeries.
A Scrotoplasty can be performed with both the metoidioplasty to phalloplasty with testicular implant placement to create the appearance of a scrotum with testicles.  The scrotum is created by opening and joining the two labia majora (big lips).
In addition to these surgeries it is possible to have a hysterectomy at the same time as the “bottom” surgery. I work with a team of gynecologists that can perform the hysterectomy at the same time.

Q: If I can’t get an erection with a phalloplasty, can I still have intercourse with my penis?

A: Yes, you can create an erection by wrapping the penis in Coban™ (thin elastic medical dressing) and then you can have intercourse by covering the penis with a condom.

Q: After having bottom surgery can I still have an orgasm?

A: Yes. The clitoris is transposed to the pubic bone. If an individual or partner stimulates the base of the penis (instead of focusing on the head) you should be able to have an orgasm. A very small percentage of folks have loss of orgasm due to scar tissue covering the clitoris after surgery.

Q: How do patients fund their surgeries?

A: Unfortunately, insurance does not usually cover these surgeries. In all the years that I have been performing these surgeries I only ever had one case that was covered by insurance.  It is important to understand that insurance coverage for a surgery is not based on the insurance company; it is based on the package purchased by the employer for its employees from the insurance company and most companies do not purchase packages that cover transgender surgeries.
Most Medicaid and Medicare plans do not cover transgender surgeries. In addition, most insurance companies purposefully have statements saying they exclude transgender surgeries.
I work with a couple different financing companies that patient can use to get loans to pay for their surgeries.
Be aware…..submitting a surgery for coverage with an incorrect diagnosis just to get insurance to pay for it can be a problem.

How?
If insurance excludes gender reassignment surgery and a surgeon submits a claim despite this, the patient and provider could be charged with insurance fraud. (A common example of this type of fraud is a FTM patient submitting an insurance claim for a breast reduction with a diagnosis of gynecomastia). Along with facing the legal penalties for these actions, the patient may have difficulties in the future accessing health insurance due to previously “committing” insurance fraud.

Q: What should I think about when choosing a surgeon?

A: Here are some things to think about:
-Interview multiple surgeons. If you are out of state they should be willing to speak with you over the phone; they should provide you with multiple before and after photos from a variety of clients.
-Ask to speak to previous clients about their experience with the surgeon.  Did the surgeon provide good care before, during, and after the surgery?
-Have a clear understanding of the procedure you are getting and ask the surgeon to explain what they are planning to do.
-Be aware of where the surgery will be performed. Will it be performed in the surgeon’s office, a surgery center, or at a hospital?
-If it is not performed in a hospital is the surgeon affiliated with a hospital? Does that hospital meet certification requirements?                                                                                                             -Does the location where your surgery will be performed (the surgery center, hospital or surgeon’s office) meet state surgery center codes?
-Will the surgeon use a CNRA (certified nurse) or an anesthesiologist? Be aware that, although a CNRA (certified nurse) is less expensive, they have less expertise which may be a problem if there is a complication.
-Will your surgeon be available for questions after your surgery?
-What follow-up visits are included in the cost of the surgery?
-What is their revision policy? Some surgeons say that they will waive their revision fee for up to a year and the client will only need to pay for the OR and the anesthesiologist.
-Is the surgeon performing the procedure committed to transgender surgeries for the long haul?
-Is the surgeon board certified?
-How much surgical experience do they have?
-How much longer will your surgeon be in practice? Will they be available to support any complications that may occur at a later date?
-Do they have a sense of the surgeries or are they experimenting?

Q: I’m thinking of having a surgery abroad. What are some things I should consider?

A: Think about these points:
-Will you receive the same standard of care abroad that you would in the U.S.?
-What are the blood screening protocols for HIV, Hepatitis, etc.?
-What types of complications are associated with the surgery and what would be the additional expenses should I have to stay longer in the hospital and change my travel plans?
-If I have a complication after I return to the U.S. will I be able to get in contact with my doctor abroad?
-If I have a complication after I return to the U.S. and my doctor abroad will not treat me will I be able to get a doctor in the U.S. to treat me and if so, how?

Q: What are some financial concerns I should think about?

A: Along with preparing to pay for the surgery you need to prepare for complications. How much will it cost to stay in the hospital for an extended period of time? Along with the cost of the visit, how much work could you miss? Can you afford to take that vacation or loss in pay? Will you need to pay someone to take care of pets or children?

Q: Are there any health concerns I should be aware of after my surgeries?

A: Along with the potential complications of the surgeries, individuals who have had top surgery need to be aware that you still have the potential to get breast cancer. Some of the tissue is left behind. If you do not have a hysterectomy you need to still receive gynecological care. You may feel disconnected or want to be separated from those parts of your body, but they still need care.
Also, hormone therapy should be prescribed by a medical professional and you should have the appropriate monitoring after you start hormone therapy. There are a number of health issues that you should be aware of and incorrect dosing can be problematic.  For example, while taking testosterone can reduce your risk for ovarian and other cancers, if you are taking too much, your body will convert it into estrogen and this can actually increase your risk of cancer.

I hope this interview helps to answer questions you might have and let you know what procedures are available to you.  If you should have any other questions or are interested in setting up a consultation to discuss the options that would be best suited for you please feel free to email me at drkathyrumer@drkathyrumer.com.  As I mentioned earlier you can also visit my website at www.transphilly.com.