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Episode 20 Transcript

Gender Affirming Surgery with Gabriel Del Corral, MD, FACS

Introducing Dr. Gabriel Del Corral

Erin Everett: Hey everyone. Welcome back to Exclusively Inclusive. I’m your host, Erin Everett. On today’s episode, I’m really excited to be interviewing Dr. Gabriel Del Corral, who’s a gender affirming surgeon that works in Georgetown University hospital. Dr. Gabriel Del Corral was amazing to interview. He has a lot of experience, he does not just serve the gender community. He has experience in all types of different surgeries. However, in today’s podcast episode we’ll be focusing more on what he can do for gender affirmation.

The types of procedures that Dr. Gabriel Del Corral does is expansive. And he does a lot for the gender community. So we’re going to be talking in more detail about each type of surgery he does and what to expect from the outcomes and recovery and what kind of preparation you might need before those surgeries. I know a lot of you have a lot of questions about gender affirming surgeries and what they entail, so hopefully you get some answers out of today’s episode.

Dr. Del Corral has been recognized for his advanced techniques and abilities throughout his career. Today he performs over 400 breast surgeries per year and over 200 gender surgeries per year. That’s a lot. He also does a lot of “second opinion” consultations every week. Whether people have already had surgery elsewhere or they’re just scoping out different surgeons. A lot of the times people end up going with Dr. Gabriel Del Corral because of his personal touch. He and his team are really focused on delivering individualized care for every individual that reaches out to them.

I noticed that when I was talking to him that he’s a very genuine person, and I think he and his team try really hard to make sure that the patients understand what to expect and that they do everything in their power to make sure that insurance is going to get coverage for you. And if not, and if they cannot do that for you, they’re very up front about what the expected outcome and cost might be from each person and what procedure they’re seeking.

He has actually won top doctor every year since 2015. He was most recently nominated top doctor in 2018 for all of his surgical pursuits. He’s amazing, and I cannot wait for you guys to talk to him and get to meet him. Without any further ado, let’s talk to Dr. Gabriel Del Corral.

Erin Everett: All right, welcome to the show Dr. Gabriel Del Corral.

Gabriel Del Corral: Thank you so much for the invitation. It’s truly an honor to be here with everybody talking about this very important subject.

Erin Everett: Yeah we’re really happy to have you.

Gabriel Del Corral: Thank you so much.

Erin Everett: Yeah. Before we get started, why don’t you go ahead and introduce yourself and let us know your preferred pronouns and some fun facts about you that maybe people don’t know about.

Gabriel Del Corral: Sure. My name is Gabriel Del Corral. I’m a plastic surgeon in the Baltimore and D.C. area. My pronouns are he and him. And I’ve been doing gender affirming surgery for the last four years. Some of the fun facts about me, I’m originally from Panama and came to the United States specifically to train and ended up staying here. I’m a big car and kite boarding fanatic.

Erin Everett: Oh, cars. What kind of cars are you into?

Gabriel Del Corral: I like anything that has some degree of speed. Classic, modern, anything.

Erin Everett: Yeah, yeah. I could see how that would be really a fun way to spend your weekend when you’re not working.

Gabriel Del Corral: Absolutely.

Erin Everett: Excellent. How did you get into gender affirming surgeries? What brought you to that field?

Gabriel Del Corral: That’s a great question. I really started doing gender affirming surgeries secondary to having a lot of patients who came and spoke to me looking for top surgery. It wasn’t until I went and traveled and visited many centers that I really fell in love with the technical aspect of specifically the genital surgery aspect of the procedure. A little background for me, my godfather was a gender affirming surgeon in Colombia. He was a GYN and he did a lot of vaginoplasties. I remember when I was growing up, going to his office and seeing this beautiful trans woman in the office, and it always caught my attention. I think there’s a little bit of genetics into it as well.

Erin Everett: Yeah, for sure. It’s great to have a nice strong role model as well to show you something that has a lot less exposure.

Gabriel Del Corral: Oh absolutely, absolutely. And it’s very interesting to see his communications and interviews in the newspaper for what it was back then and what it is now. It’s really evolving and changing positively.

Erin Everett: Yeah, absolutely. Well that’s great, and the community is really glad to have another ally on board willing to increase access to care. And with all that in mind I think it’s really important that we touch on some of the surgeries that we do. What kind of services do you include when it comes to gender affirming surgery?

Gabriel Del Corral: Right now we have a multi symptomary center that really with other specialties we’re able to offer majority of gender affirming procedures starting from facial feminization to neck feminization such as tracheal shave. We do top and we do bottom surgery. The only service that we don’t provide is any type of voice surgery or any type of vocal training at the moment.

Erin Everett: Okay. Yeah, is there plans to incorporate that in the future since you said at the moment?

Gabriel Del Corral: Yeah I think there’s always a role to improve and expand. I would love to at least have a person, a therapist specifically training on vocal training. As the vocal surgery part itself, I think you do need to go to a specialized center with a lot of experience for that delicate surgery.

Erin Everett: Yeah. Yeah. I would agree with that. It’s highly specialized. And in the research that I’ve done there’s not that many people doing it, and those that are there’s even fewer that are doing a really great job at it.

Gabriel Del Corral: Exactly.

Erin Everett: So I would agree with you on that for sure. With that in mind, one of the things that I think people in the community look to is kind of how many patients are you treating, and what kind of outcomes are you getting with each type of surgery?

Gabriel Del Corral: Sure. That’s a good question. It’s a bit broad. Let’s go ahead and just sort of maybe divide the question into maybe top procedures and bottom procedures.

Erin Everett: For sure.

Types Gender Affirming Surgeries Dr. Del Corral Conducts

Vaginoplasty & Phalloplasty

Gabriel Del Corral: I think right now when we look at our yearly amount of cases that we’re doing, we’re doing a high number of top surgeries. Usually anywhere between 75 to 120 cases a year of top surgery. And that’s a combination of chest masculinization and chest feminization of course. We do a good number of genital surgery as well. We do over 50 vaginoplasties each year and about 25 phalloplasties every year. And I think when we look at outcomes, and you mentioned a great buzzword which is outcomes. What is outcomes? Outcomes means really how good are we doing, and are our patients happy? And more importantly, are patients having a relief in their dysphoria after what we’re doing.

Erin Everett: Right.

Gabriel Del Corral: As part of Georgetown faculty, we’re trying to gather data and do research to evaluate these questions that you’re answering. And I think for the most part, I think the complications for the surgeries, specifically for things like top surgery and vaginoplasties, the complication rate is quite small. If there’s complications, they’re very easily managed. Phalloplasties obviously is a little bit more technical. There’s more room for error as the patient has a more complex procedure. I think things like facial feminization are really really on a lower end of complications with much higher satisfaction rate for our patients. It’s really neat to see sort of the different procedures and the impact they have on our patients.

Gabriel Del Corral: But for most procedures are actually fairly safe if going to the right place and patients are obviously counseled against the potential complications of course.

Facial Feminization Surgeries

Erin Everett: Mm-hmm (affirmative), yeah for sure. And to your point about being more broad versus specific, more specifically when you’re talking about facial feminization surgeries and patients having really pleasant outcomes, what kind of things are you incorporating into the facial feminization process?

Gabriel Del Corral: Yeah, the facial feminization, it’s about building harmony in the face and achieving a lot of that feminine contour. But it’s so variable between one patient and the other that there’s no really cookie cutter recipe that one patient is going to come in and is going to say, “Okay you get the facial feminization package.”

Erin Everett: Right.

Gabriel Del Corral: It just doesn’t work that way.

Erin Everett: Right.

Gabriel Del Corral: I really try to focus to see what actually the patients are bothered. Because a patient may come in with a brow ridge or frontal bossing, and I’m thinking in the back of my mind maybe the patient would like to have that addressed and the patient doesn’t even mention that.

Gabriel Del Corral: We really offer anything from a forehead set back to contouring to rhinoplasty to face lift to more of the mandible work. And that’s all incorporated in the realm of facial feminization.

Erin Everett: Mm-hmm (affirmative).

Varying Outcomes for Gender Affirming Surgery

Gabriel Del Corral: But really I can’t tell you that I’ve done the same procedure on two patients because it’s just so variable. There’s also insurance limitations of course. And there are limitations on what the insurance can cover, versus what you can cover in a cosmetic cash fee basis, of course. We have to be sensitive to that. We cannot just offer something that is going to be super exponentially expensive knowing that that’s something the patient may not be able to afford. So we have to be cautious in how do we present that and make sure that we’re transparent and telling the patient what are the options and what can be accomplished.

Erin Everett: Mm-hmm (affirmative). Yeah, I really love that you mentioned that no two patients are alike and that you don’t practice cookie cutting surgery. Because that’s how we practice medicine in our clinic, and I try and remind patients that everybody’s journey is going to be different. Their hormone dosing is going to look different, their outcomes are going to look different, and of course the same holds true for surgery. I think it’s really important that you’re having that conversation with people so they can reset their expectations of surgery as well and what that might look like for them as a person.

Surgical Limitations

Gabriel Del Corral: Yeah, absolutely. I think it’s important to really have the patient understand what are the limitations with the surgery and what can be accomplished. It’s the same thing as we don’t offer a catalog of where the patient can choose what result. They can be similar results, but it’s very difficult to achieve a very similar or equal result based on all the changes or the variables such as skin texture, skin color, skin thickness. Just taking that small variable of skin, it can give you for example a breast augmentation result that is very different. It’s important for patients to sort of understand that aspect of surgery.

Potential Scarring & Keloiding

Erin Everett: Yeah, absolutely. And you touched on it, and I was going to ask you about that. When you say skin color and texture. Now for patients who are in the community and have more … people of color, their skin tone is darker. And they may have concerns about abnormal scarring or keloiding. Is that something that you run into a lot? And if so, are there solutions for that? Or these patients kind of have to deal with that as a possible aspect?

Gabriel Del Corral: Yeah, no, that’s a great question. I think there are some areas that are more prevalent and sensitive than others. I can tell you for example, and just using an example, sometimes doing a procedure that requires an incision in the chest for example, which is a much mobile area, if I’m operating in someone with black or brown skin, they’re more likely to develop hypertrophic scarring in that chest area. So we are much more aggressive in using scar care modalities to decrease that. There’s different things you can use. Creams, silicon sheets, to even counsel the patient, “Hey we know this is a huge possibility. We know that we have to cure your dysphoria, and we want to make sure we do this for you. If this were to happen with the keloid, these are the options.”

Erin Everett: Right.

Gabriel Del Corral: Because there are always options, Erin, and there’s things that we can do. It may not be fully preventable during the first surgery, but there is possibilities that we can maybe remove it and give other modalities to decrease it.

Gabriel Del Corral: And vaginoplasty, we don’t see that keloiding, hypertrophic scaring so often for example. It’s an area with a little bit less mobility. There can be widening of the scars, but we don’t see the same issues with keloids as well. But again, it’s something in the back of her mind of course.

Erin Everett: Of course.

Gabriel Del Corral: Patients ask me, “Are you going to do something different in the closure? Is there something that you …” and as plastic surgeons, we always strive to do a multi layer closure, try to make it look as pretty as we can. That’s a given from the get go. I think there’s a lot of variable depending on where you’re doing that incision, that the result can vary.

Erin Everett: Yeah. Absolutely, I think that’s really good. And I think probably even having that conversation with the patient again, making it a realistic expectation is even more valuable than any solution it could present so they’re not waking up shocked. You know? Or going through the recovery shocked at possible outcomes. I think anytime you’re doing something with someone and you present all the possible variables, it inevitably makes the outcome more manageable.

Gabriel Del Corral: Yeah. I agree with you. I think a lot of people see us sometimes as really technicians than surgeons. But the reality is that we got into this field to really advise and care for patients throughout the process. And I feel like the relationship I have with my patients when they come from a gender affirmation journey, it’s not something that it’s just a one month or three month or six month follow up. It’s really years of follow up and making sure they’re doing well and being there for them throughout the process, and guide them through that. It’s completely new for them.

Continued Relationship Following Gender Affirming Surgery

Erin Everett: Right. During that time then, are you in your clinic available to them for outreach? And what does that look like? Is it easily accessible to reach out to you and your team for questions? Even a year after their procedure?

Gabriel Del Corral: Oh absolutely. I tell my patients I’m the easiest man to find because you can either send us an email through the website, it goes directly to my email. You can text me, you can find me via email, you can find me through the med star health system. It’s very, very easy to find me. Yes. And now with technology, it’s so easy to send an email from anywhere in the world. I think it’s easier to be accessible for our patients.

Erin Everett: Yeah. And technology too. With probably a lot of your patients not being local, and being able to video chat and stuff helps out a lot, right?

Gabriel Del Corral: Yeah, video chat has really changed my practice. As you know, what about that patient who had maybe a top surgery and is worried about the nipple graft? Hey, it only takes one second to take a picture and send it, and we can really provide peace of mind. Because back in the day if that were to happen on a Friday, you won’t get an answer maybe on Monday or Tuesday.

Erin Everett: You’re right about that.

Gabriel Del Corral: It’s definitely helped us to be better at what we do.

Erin Everett: Yeah. That’s awesome. And it’s nice and reassuring, comforting to patients. Because as a provider who is trying to vet out resources and make sure that my referral base is solid and that they have a good experience, one thing that patients are concerned about is that they will go to another state, have their surgery, come back and we’ll be kind of left in no man’s land without any support when things pop up. Whether it’s if you’re talking about vaginoplasty, a lot of patients will experience changes in discharge. They haven’t had this organ before, so it’s all uncharted waters. And to know that that support is easily accessible is huge for them.

Gabriel Del Corral: Absolutely.

Gender Affirming Surgery Insurance Considerations

Erin Everett: Yeah … The other thing that I was going to ask you about when it comes to that type of thing, you were talking about insurance having limitations. I wanted to touch on that before we went further into the actual details of surgery. Because that is one thing I get asked about a lot, is are you finding it easy for insurance and payers to pay this for these procedures? And if so, are ones covered more than others? I imagine probably vaginoplasty is covered more than facial feminization, but maybe not. And is your office assisting that with patients?

Gabriel Del Corral: Yeah, absolutely. We spend a huge amount of time navigating through the insurance world.

Erin Everett: Yeah.

Gabriel Del Corral: I can tell you that from now to when I first started, insurances are certainly approving these procedures a lot easier than before. I used to be on the phone with the medical directors for insurance companies every week about procedures. I just don’t see that anymore. I think the only variability with insurance are two things that patients need to be aware. Sometimes there are specific exclusions. In that specific subtype of insurance that the patient may have. And even though they may say I have X, Y insurance, which is a very broad well known carrier, they may have an exclusion in their actual insurance policy that may not cover gender affirmation procedures. That’s something to know as well.

Gabriel Del Corral: The other important factor is that there are also insurances variability in the amount of information or letters required for procedures. Some insurance require one, some require two. And it’s completely independent what WPATH wants. There’s different criteria, and patients need to understand that depending on their insurance they should contact their insurance company to see those specific requirements. And there’s no question that for anything that is below the neck, those procedures are much easily covered. Facial feminization, at least on the East Coast, it’s still a challenge to get this procedure covered.

Erin Everett: That’s what I figured.

Gabriel Del Corral: However, I am seeing a little bit more and more of changes. Hopefully in the next five, 10 years we’ll have that completely change. The only way to change it is showing the insurance company patient reported outcomes that our patients are doing better. For that we also need to collaborate and put our scientific coat to really try to help out and really produce data that can be useful to advocate for our patients.

Erin Everett: Yeah, absolutely. And I have actually had … I suspected that was the case, because I have had patients who have come to me upset because they don’t understand why is a bilateral mastectomy for top surgery covered when my facial feminization surgery is considered elective and cosmetic. And it comes down to us having to advocate for them, but them also having to advocate for themselves. Nine times out of 10 it’s because a lot of insurance companies or human resources who are dictating the benefits covered have no idea that facial feminization is considered medically necessary in gender affirming surgery. They don’t know it’s a thing. So they’re still considering well your brow bone being shaved and adjusted is elective, whereas it’s not. It’s very medically necessary in someone who has a lot of dysphoria surrounding it.

Erin Everett: I’ve actually had patients approach their HR departments when they are up for it, and talk to them about having it be an included benefit because it’s just ignorance. And it’s not necessarily because they are trying to be transphobic, but a lot of it is ignorance. Unless you’re in the community and educating yourself, you’re not aware that that is considered a necessary procedure.

Gabriel Del Corral: Yeah absolutely. It really amazed me to see if you really think about it, you look yourself in the mirror every day. How come we’re allowing this as the last option for patients to change their face when they have changed every other part of their body and it’s still very difficult for them to change facial features because it’s so correlated to the aesthetic world. But it’s the most important feature that we have that we identify with ourselves.

Erin Everett: For sure.

Gabriel Del Corral: It’s going to be an ongoing battle, but I think we will be able to win it at the end.

Erin Everett: Yeah, I agree. Especially with staunch advocates like yourself and your teammates.

Gabriel Del Corral: Oh thank you very much.

Erin Everett: That’s super impressive. Yeah, it’s not very often you hear about the surgeons sitting on the phone with medical directors of insurance companies trying to get procedures covered.

Gabriel Del Corral: Yeah. I think it’s the only way we win this battle, for sure.

Gender Affirming Surgery Costs

Erin Everett: Yeah, yeah, well we appreciate it … That is definitely a hot topic is insurance. When insurance isn’t covering it, are the surgical procedures too cost prohibitive for people to obtain out of pocket?

Gabriel Del Corral: You know, there’s certainly a variability in the cost of procedures. But when you’re doing procedures that are … and I’m not talking about the soft tissue, like the face lift and the rhinoplasties, but things that require changes in the kind of facial structure of someone, requires planning. For example any type of forehead or set back or mandibular set back, that requires the evaluation of the CAT scan and there is a lot of virtual planning that we do before those surgeries. It also requires special instruments to get in someones, that area, and do a good job, a precise job. And that just elevates the cost sometimes to be quite high, to be honest with you.

Erin Everett:
Right.

Gabriel Del Corral: But I think that’s for patients who really require the typical set back or a significant genioplasty which is sort of advancing or reducing someone’s mandible. But there is a gray line. There is some patients that do not require a big change. And that certainly can be affordable for sure.

Erin Everett: Yeah, for sure. That’s good to know. With insurance and out of pocket stuff aside, some of the other questions that people have written in about would involve things like what kind of conditions or underlying medical issues or whatnot would make someone not a candidate for vaginoplasty?

Health Conditions & Vaginoplasty Candidacy

Prostate Cancer/Prostectomy

Gabriel Del Corral: That’s a great question, and I get that question asked a lot of the time. I just want to clarify, we’ll divide into conditions, and I think other things like patient factors are sort of what are the red flags. And I think when you talk about conditions, I think that any patient who has had any type of radical prostatectomy for prostate cancer can have difficulty in creating the canal that is required for a vaginoplasty, because that usually gets radiated. Those patients may want to consider the procedure or get a further MRI to evaluate the area. And some of those patients may just go up to do a vulvoplasty. But it depends on the scenario.

Tissue Disorders, Smoking, Obesity

Gabriel Del Corral: A lot of times they ask me about kinetic tissue disorders. And I have operated in a number of patients with connective tissue and I have not found to be a higher increase of wound healing complications. I think the two main challenges that are common that are risk factors are smoking and patients who have a BMI greater than 35 or 40. Those are red flags for poor wound healing. I strongly don’t recommend it, because not only you have problems with wound healing, it’s difficult to also obtain a good canal. Patients also have difficulty being able to access the vaginal area for dilation because their abdominal size. All those factors can lead to a poor vaginoplasty result.

Erin Everett: Mm-hmm (affirmative). Yeah, I can imagine too that that would be the case, especially with smoking. And it’s not just for vaginoplasty, but a lot of surgeons are hesitant to perform unnecessary/not-life-saving procedures on patients who are still smoking, because of the poor wound healing.

Gabriel Del Corral: Exactly.

Erin Everett: Yeah. You touched on radical prostatectomy maybe not being a great option for a full depth vaginoplasty, but would be considered for vulvoplasty. Which presents my next question or leads us into it. A lot of patients ask me about the difference between the two of those procedures, and why one would be better than the other.

Vaginoplasty vs. Vulvoplasty

Surgical Differences

Gabriel Del Corral: Great question. I think that there are two main differences between the vaginoplasty and the vulvoplasty. Obviously the vaginoplasty does have a vaginal canal, and the vulvoplasty doesn’t have a vaginal canal, but the exterior part of the genitalia looks like a vaginoplasty. It’s what it is. Vulvoplasty means just the exchange or the change of the external anatomy so it looks the same. And I’ll tell you the typical patient who doesn’t want to do a vaginoplasty, patients who sometimes are a bit older or not interested in dilation. Perhaps they have a female partner and they’re not interested in penetration of any kind. Those patients usually will require or seek a vulvoplasty. A vulvoplasty hospitalization is usually about two to three days, versus a vaginoplasty can range between five and seven. You can see how the recovery time, the hospitalization is much different between the two of them.

Erin Everett: Mm-hmm (affirmative). For the people in the community listening, the vulvoplasty is often referred to as zero depth for lay people, because of a lack of the vaginal canal, is that right?

Gabriel Del Corral: Exactly. Exactly.

Cost Differences

Erin Everett: Okay. Yeah, for someone who’s unsure and maybe cost is a factor because insurance isn’t covering it, would you say the two procedures have a significant cost difference?

Gabriel Del Corral: Absolutely. Just if you base it just on OR time, the time it takes to do that work, there is usually about an hour and a half to two hour difference between the two procedures. That’s going to translate into changes in the cost of the procedure as well. Also the risk is almost much less-

Erin Everett: Less.

Gabriel Del Corral: Because you’re not creating any potential injury to the rectum or the bladder. It’s a much safer operation than the vaginoplasty.

Erin Everett: Okay. What about sexual function with either or both of them?

Sexual Function Differences

Gabriel Del Corral:
I love that question. Sexual function is one of our really priorities when we talk to patients after their surgery, especially six months out, a year later. We want to see how is their sexual function. In sexual function we look at different things including the ability to orgasm, their ability to feel comfortable while having sex.

Erin Everett: Right.

Gabriel Del Corral: And if you look at my experience and also just looking at the papers and the data out there, sexual function is quite high. A lot of the patients have good capability for orgasms after the surgery, for both procedures. I would say greater than 80% of the patients are able to achieve an orgasm. And I also find that if patients are able to orgasm prior to surgery, they will be able to orgasm after the surgery. But if you have someone who’s not able to orgasm prior to surgery, it is unlikely that they will orgasm after the surgery. Something to consider.

Erin Everett: Yeah that’s a super interesting point that I have not heard been brought up before. Yeah that’s a really interesting factor of course. Now when you’re saying both they’re able to orgasm, just for clarification purposes, and I tend to ask questions that other people wouldn’t, but I know people are thinking it. Are they orgasming via the new clitoral hood, or has it got to do with prostate stimulation?

Gabriel Del Corral: Yeah, no, when we assess the function, when we ask orgasm as a parameter, it’s primarily the clitoral sensation, clitoral stimulation. The prostate is left behind. Some people prefer it as the P spot.

Erin Everett: Oh I like that.

Gabriel Del Corral: It does have some erogenous sensation of course, but that’s usually not evaluated or unaffected after the surgery. We focus on really clitoral sensitivity.

Erin Everett: Okay. For full vaginoplasty and the P spot, is the vagina that you’re building out able to accommodate an average sized penis for penetration? Probably not immediately after, but with continued dilations?

Dilations & Penetration Post Vaginoplasty

Gabriel Del Corral: Absolutely, yes. The average canal can be anywhere between four and six and a half, seven inches. It certainly with good discipline of using the dilators, you’d be able to accommodate, like you mentioned, a regular sized penis. It just takes work after a vaginoplasty. It takes a lot of discipline. And it takes a lot of time to be able to dilate three times a day for the first couple months post-surgery.

Erin Everett: Right, right. You said for the first couple months. After that, does the dilations decrease in frequency? Does it have anything to do with sexual use?

Gabriel Del Corral: Yeah. Everyone has a little bit of a different recipe. Every surgeon has a different recipe when it comes to dilation. But yes, as you go back to month three, to six, the dilation becomes less frequent. Maybe once a day, then maybe every other day. If a patient is having regular intercourse, that counts as dilation and the patient may not need to dilate that day. There’s variability in the formulas.

Erin Everett: Yeah.

Gabriel Del Corral: Certainly for the first year, it’s almost universal that you’re going to need to be regularly dilating.

Erin Everett: Okay.

Gabriel Del Corral: And patients get familiar. They know more than anyone else or more than any formula how things, how tight things are looking or things are feeling a little bit better. Maybe I’ll stop dilating today, I’ll dilate on the next day and so forth.

Erin Everett: Yeah, yeah. And with penetration, whether it’s a human phallus or a toy, what not, the P spot, the prostate, is that able to be stimulated via intercourse in that way?

Gabriel Del Corral: Exactly, yeah.

Erin Everett: That’s what I thought.

Gabriel Del Corral: The P spot is actually closer now. Because it’s sort of just really one layer. Before you had to sort of manipulate it through the rectum.

Erin Everett: Yeah.

Gabriel Del Corral: And there’s some tissue in between. Now the tissue in between is gone, and now there’s a vaginal canal.

Erin Everett: Yeah.

Gabriel Del Corral: That’s certainly easier access.

Erin Everett: Okay. That’s great. Because I know that’s all the things that people are thinking, and sometimes don’t want to ask. I appreciate you answering those questions.

Gabriel Del Corral: Of course …

Vaginoplasty Sexual Function Patient Outcomes

Erin Everett: As far as that goes too with sexual function and whatnot, do you find that your patients are as satisfied with their outcomes in that regard? You said a lot of them have sexual function, but is it what they thought it would be? Are they happier than they thought they would be? Kind of where do they usually fall in the spectrum when it comes to that.

Gabriel Del Corral: Yeah, I can tell you that my general impression is that most patients are very satisfied. It does take a little bit of exploration to sort of get into that familiarity and be able to achieve orgasm and satisfaction. But for the most part, patients are quite happy.

Gabriel Del Corral: I can tell you that patients are generally not happy are sometimes patients that develop any type of complications or for some reason they stop dilating and they lost a portion of the canal. Those are the patients who generally are less happy with the procedure and may require other procedures and other options.

Erin Everett: Mm-hmm (affirmative). When you say they lost a certain depth of their canal, is it possible to get that back without surgery?

Gabriel Del Corral: It’s very difficult, depending on the time being to obtain any length. More commonly patients need to have some other surgery, and of course that surgery can be a little bit more challenging than the first surgery as there’s more scar tissue now.

Phalloplasty & Metoidioplasty Gender Affirming Surgery

Erin Everett: Yeah, for sure, for sure. Excellent. Okay. Then when it relates to all of that, moving on from vaginoplasty, I think it’s also really important that we touch on phalloplasty. Because I feel like that’s even less talked about. The surgical options are more limited depending on who you talk to, and the surgeries are far more extensive. Would you believe that to be correct?

Gabriel Del Corral: Oh 100%. I think that I tell all my patients that the complication rate for a phalloplasty, it can be 100%. It could be a small opening, but it’s 100%. There’s something that is going to happen. The question is how do we as surgeons really try to navigate to minimizing all that potential issues. And there’s different ways to do that to have a good outcome.

Erin Everett: Yeah. Do you perform both the phalloplasty and the metoidioplasty?

Gabriel Del Corral: At our center I perform the phalloplasties and my urologist will perform the metos.

Phalloplasty vs, Metoidioplasty

Erin Everett: Okay. Can you briefly just describe the difference between those two procedures?

Gabriel Del Corral: Sure. Metoidioplasty is really the elongation of the hypertrophy clitoris. In other words, hormones are given, the clitoris is enlarged. Sometimes you can put a little topical cream on the clitoris and use a small pumping device. And that all causes clitoris to enlarge, almost like a small penile corona or tip.

Erin Everett: Phallus, yep.

Gabriel Del Corral: Then what we would do is with the using of the local tissue, we would just elongate the urethra. The patient is able to urinate through what we call a microphallus. But the idea is that they can stand to urinate. But it’s not enough to have penetration.

Erin Everett: Right, okay.

Gabriel Del Corral: Although sensation is great because it’s the same clitoris, it hasn’t been moved, it hasn’t been reattached and reconnected. So sensation tends to be quite good in that.

Gabriel Del Corral: Phalloplasty, you’re really building something out of nothing.

Erin Everett: Yeah.

Gabriel Del Corral: And after you build it, you have to makes you’re that not only it has good sensation, but also the plumbing has to be correct so the urine can pass through the phallus. That adds complexity to the process.

Erin Everett: Yeah, for sure. Do you typically … how many stages do your phalloplasty procedures usually entail?

Gabriel Del Corral: Yeah, again Erin, I think that the phalloplasty world can be done in two ways. There’s really no one recipe or one way to do it. Generally if the patient wants to have a radial forearm procedure, we generally like to do everything in one stage and do the urethral lengthening at the same time. And the reason I do it at the same time is because I have an excellent urologist that works with me that specializes in urethraplasty. Not every center, not every place that is doing a phalloplasty has that option.

Erin Everett: Right.

Gabriel Del Corral: So we’re able to do everything in one stage, meaning the phallus and the urethra. Then obviously the second and third stage would be any type of implants that will happen a year later.

Erin Everett: Right.

Gabriel Del Corral: Usually when we do a radial forearm, the anatomy is reliable, the blood supply is really good. Versus the thigh flap has a little bit more variability in the blood supply. And for that reason we like to just sort of do the phallus first, then we’ll come back and do the urethra lengthening later or connect the urethra later.

Erin Everett: Interesting.

Gabriel Del Corral: That would be a two stage for that part versus a one stage.

Phalloplasty & Metoidioplasty Patient Outcomes

Erin Everett: Mm-hmm (affirmative). Which one tends to have the best outcomes in your opinion, in your experience?

Gabriel Del Corral: Yeah, I think if you want the best sensation, and I think sensation is one of the priorities after this procedure-

Erin Everett: For sure.

Gabriel Del Corral: I think the radial forearm has just anatomically the nerves are better and the blood supply is better as well. But of course the area where you’re taking the flap just leaves quite a large scar that needs to be covered. And that’s a turnoff for many patients of course.

Erin Everett: Right, yeah. That’s interesting that there’s such a marked difference though between the sensation. Do you feel like if someone, their top priority is trying to maintain sexual function post operatively, that you would encourage them to get the radial forearm flap?

Gabriel Del Corral: I think that if they have the willingness to use the forearm, I think it’s a great option.

Erin Everett: Yeah.

Gabriel Del Corral: It tends to be a little more pliable and have the nicer aesthetic phallus as well. The thigh and occidental culture here in the US tends to be a little thicker, and that can carry a phallus that is just, you know, quite large and quite thick, and it may require a lot of revisional procedures for patients. That’s something to consider as well.

Erin Everett: Wow. That is really interesting. I just feel like there’s so many things I could ask you.

Gabriel Del Corral: Go ahead, go ahead.

Erin Everett: All of this is super fascinating. Patients, they don’t always have the opportunity to have access to talking with a surgeon and asking them these questions so I really appreciate you answering all these. A lot of people ask me and I’m like, “I don’t know, I’m not a surgeon. But I’ll try my best to find out the information.” You know? I’ve got the hormones and stuff under wraps, but the other stuff I leave it for people like you …

Orgasm Post-Phalloplasty

Erin Everett: When you’re talking about the differences in those two and one has a greater opportunity to have more sensation, in general do people who undergo phalloplasty have good sensation afterwards? Are they able to attain orgasm?

Gabriel Del Corral:
Yeah. I think it takes time. I think the sensation is a process that may take a year to two years to get sensation in the phallus.

Erin Everett: Wow.

Gabriel Del Corral: And sometimes the sensation is pressure sensation, it’s not an erogenous sensation. That’s why we like to leave the clitoris at the base of the phallus so that can be stimulated as well.

Erin Everett: I see, okay.

Gabriel Del Corral: But it’s a process that can take some time. But most patients, the key to be able to have sensation is really time and also once that happens then we can talk about implants.

Erin Everett: Right.

Gabriel Del Corral: But we can’t really put an implant in an area you can’t feel, because that can lead to complications and problems with excrusion and things like that.

Typical Phalloplasty Patient Concerns

Erin Everett: Oh I see. Yeah, yeah. When you’re talking to patients and they’re coming in the office for a consult, what do you find that patients are most concerned about when it comes to masculinizing affirming surgery?

Location of Donor Tissue

Gabriel Del Corral: Yeah, I think when you’re talking about genital surgery, I think one of their biggest factors that patients will worry about is really the donor side. Where is the tissue coming from?

Erin Everett: Really? Okay.

Number of Surgeries Necessary

Gabriel Del Corral: And the second biggest question is how many surgeries am I going to need to accomplish where I want to be. I think patients are very, very knowledgeable and understand that this is sort of a long journey. It takes about two years to complete, and it may require multiple surgeries. I think those are the two main concerns that patients have.

Erin Everett: Yeah. And you bring up a valid point. It’s extensive surgery, people are concerned about it, they’re aware this is a long recovery time and it’s going to be a long journey. Is there anything that people like you in your field are working on to kind of change the face of masculinization surgery?

Gabriel Del Corral: Yeah, there’s ongoing, a lot of innovation happening. From a technical standpoint to decrease the amount of complications to the innovation of ways that we can improve the neurotization or the sensation when we connect nerves. There’s a lot of ongoing changes that I think in the next 10 years the way we do phalloplasty will be a lot different. If you put it in perspective, we used to do many surgeries in multiple stages, such as breast reconstruction. Now we do it all at once. And I foresee the same thing happening for gender affirming procedures, especially a phalloplasty.

Erin Everett: Mm-hmm (affirmative). Yeah, we’ve come a long way but we have a ways to go, right?

Gabriel Del Corral: Absolutely. That’s what keeps us going and still intrigued and trying to really answer questions.

Types of Vaginoplasty & Future of Gender Affirming Surgeries

Peritoneal Vaginoplasty

Erin Everett: Yeah, right. And you know, since we’re mentioning possible new developed surgeries, you had mentioned that you’re offering a peritoneal vaginoplasty. What does that entail? I’m not really aware of that.

Gabriel Del Corral: Yeah. A peritoneal vaginoplasty is a procedure that was developed a long time ago by using the peritoneum, which is this very thin shiny layers that covers everyone’s abdomen. I didn’t develop this operation, but it was developed already. The idea is for you covering the inside of the vaginal canal with this peritoneum. The challenge is that you have to … being in a specialty, multidisciplinary place where you have robotic surgeons that can use the peritoneum from inside your abdomen to cover the inner lining of the vaginal canal. Exteriorly it will look the same, but the peritoneum function is to cover the vaginal canal. And we have had good experience using this procedure for revision cases for patients who have lost the canal for different reasons. And we’re able to obtain resurface the canal again. Some patients even refer some moisture coming from the canal. But there’s really very little data about the moisture factor.

Gabriel Del Corral: I had the opportunity to actually look at two patients who had the procedure over a year ago. And looking at inside and see how this tissue looks a year later. It’s really beautiful and impressive how it just really mucosalizes. Meaning it looks really nice and red, similar to a native cis female vaginal mucosa. What we don’t know, Erin, is how long is that canal going to stay open. Right? There’s no data so far. And does it require dilation for longer than a year?

Erin Everett: Yeah.

Gabriel Del Corral:
And those answers we still don’t have yet. Patients ask me why we shouldn’t just do a peritoneal vaginoplasty on everybody from the get go, because you can theoretically get more of that tissue and it may be better and the canal may be better. Well the reality is that the difference in the canal depth is not that much over time.

Erin Everett: Right.

Colonic Vaginoplasty

Gabriel Del Corral: We see that with colon vaginoplasties, and you compare that to the actual standard vaginoplasty and you look at the studies and 14, 15, 16 centimeters is an average, the amount. Which is about five and a half, six inches for those procedures. I would think over time it may not make a big difference, and you’re subjecting yourself to a much bigger operation now going inside the abdomen with other risks.

Erin Everett: Right. In general that’s not your go-to. That’s not something that you’re recommending for most patients?

Gabriel Del Corral: Exactly. Not for primary vaginoplasty yet. I think we need more information.

Erin Everett: Right. And is that what community members are referring to as the self-lubricating? Is the peritoneal?

Gabriel Del Corral: It is potentially, which is a bit of a misnomer because we generally don’t have good data on that yet.

Erin Everett: Right, right. And as you’re aware, the majority of patients won’t be able to have access to surgery or potentially even desire surgery. Even with the hundreds of patients in the gender diverse community that I take care of, really a small percentage have gone on to have full gender affirming surgery. And even less for phalloplasty, but the majority a vaginoplasty. And out of that I think only one had some sort of peritoneal procedure that they referred to as self-lubricating. That patients no longer is in my care, so I’m not able to get more information about that, but what I found fascinating was that while this was marketed to them as it’ll be more like a normal vagina, a cis vagina, it’s going to operate more like a cis vagina, their outcomes were actually decreased. They had decreased satisfaction because of the amount of discharge they experienced with it.

Gabriel Del Corral: Oh interesting, yes.

Erin Everett: Yeah. And I don’t know if that was just because of that particular person or whatnot. I don’t think in general people are necessarily desiring a self lubricating. I think most people are okay with lubricating their own organs prior to intercourse.

Gabriel Del Corral: Right, I think a lot of patients know that they’re going to need some sort of water based jelly, and a lot of patients are okay. Too much lubrication can lead to smell and odor as well. That’s what we see for colonic vaginoplasties, and some patients don’t like that.

STDs, Discharge & Treatment Post-Vaginoplasty

Erin Everett: Right. Speaking of smell and odor, STDs and risk of STDs and bacterial vaginosis, do you get a lot of questions about that? And if so, how are you managing that?

Gabriel Del Corral: Sure. It’s not something that I see frequently to be honest with you.

Erin Everett: Good.

Gabriel Del Corral: Which is great for our patients. It’s certainly a risk. Certainly it’s part of skin, it’s mucosa and the urethra, so you can certainly get an STD.

Erin Everett: Yeah.

Gabriel Del Corral: You need to take the same precautions you would do if you were having intercourse anywhere else when you have post-vaginoplasty.

Bacterial Vaginosis

Erin Everett: Right, okay. And when it comes to the bacterial vaginosis, and the reason why I ask you this and maybe it’s not something that you run into a lot, but for me it’s something I encounter of course being a primary care provider of the gender diverse community. But I’ve also heard from other surgeons in the Southeast regions talk about how the neo-vagina can actually colonize with similar flora. So the treatment for that, and I’ve had a lot of patients come in with some sort of fishy odor or gray discharge, and I’m treating them with a typical Metronidazole gels for five days like I would a cis vagina. Is that something that you have any information on or different recommendations for? Or is that kind of uncharted waters?

Gabriel Del Corral: Yeah, I think we know exactly how to deal with the problem. I think the one thing I would caution you is to make sure if it’s really early, let’s say six months after surgery, you want to make sure that there is no possibility of any fistula anywhere.

Erin Everett: Right. Always get a culture?

Gabriel Del Corral: Exactly. You want to culture it, make sure there’s nothing else going on. Because you can have … if it’s a fistula coming from the bladder, it may not necessarily be stool, but it can also create a pseudomonas infection and it can lead to that green discharge that you’re referring to.

Erin Everett: Right.

Gabriel Del Corral: I think it’s okay to treat it the way you’re doing it, as soon as you have culture information.

Erin Everett: Okay.

Gabriel Del Corral: Because the bacterial colonization is so variable and is so independent of each person that I think that I would just get true data of how to treat that infection, and not just think that it’s a vaginosis and give the Metronidazole without knowing exactly what it is.

Erin Everett: Right, yeah. I think that’s a really important point. I have cultured before, then surprised to find strep A colonized there. And I have taken care of that. And in that case too, I cultured, I treated, and was advised from somebody else that maybe reculturing wasn’t super necessary. But what are your recommendations in that situation?

Gabriel Del Corral: Yeah, I agree. Once you obtain one set of cultures you know what you’re dealing with and you have evaluated the canal and you know it’s a pristine canal, there’s no other concerns, I think just retreating it with the same antibiotics should be okay. I don’t think you need to reculture that.

Erin Everett: Okay.

Gabriel Del Corral: But at the first evaluation, I would consider culturing it for sure.

Erin Everett: Okay. And when you say evaluating the area too, do you recommend speculum exams with new vaginas?

Gabriel Del Corral: Yeah. From my standpoint as a provider and surgeon, I need to see how that area is healing. But yeah, definitely a clear gentle speculum works very well. And if the patient consents and is comfortable with that, I don’t see a problem with that. It’s just really an evaluation of the cavity to make sure there’s no problems.

Erin Everett: Excellent. Well that’s really informative. And super duper helpful. I’ll definitely keep that in mind. Especially for the infrequency of the amount of times that I’ll experience a neo vagina, especially in that early post operative period, checking for a fistula seems super obvious, but not something that’s always on our radar, so I appreciate that input.

Gabriel Del Corral: Of course.

Erin Everett: Yeah. Then also when you said checking for a fistula, for people who are listening that just usually means a tunnel between the tissue to connect two areas. May be tunneling between the bladder and the new vagina or tunneling between the colon and the new vagina. As providers we look for that.

Interstitial Cystitis & Vaginoplasty/Vulvoplasty

Erin Everett: That also reminds me to ask you about interstitial cystitis. Is that something that you find will complicate vaginoplasty or not really?

Gabriel Del Corral: Generally if the area around, if the cystitis problem has been resolved from an inflammation standpoint, it should not complicate the procedure itself. However, the patient may have issues with incontinence right after surgery, so it’s something to really be on the watch for and obviously making sure that inflammation process is completely resolved before you start in any type of surgery.

Erin Everett: Mm-hmm (affirmative), okay. For a lot of patients, interstitial cystitis especially in people who were assigned male at birth, it’s a chronic thing. And it has a lot to do with like you said, inflammation and muscle tightness. So as long as us providers are sending them to pelvic floor PT and trying to manage that, they should be okay for surgery? Or is that another person that you might encourage to do the vulvoplasty?

Gabriel Del Corral: No, I wouldn’t just say the patient if they have interstitial cystitis that they should automatically get a vulvoplasty or a zero depth. I think that patients are going to go to pelvic therapy between or they should go to pelvic therapy before their vaginoplasty regardless.

Erin Everett: Okay.

Gabriel Del Corral: And at that point it can be evaluated to see if a patient is really a candidate for a vaginoplasty and what are their risks for incontinence and other bladder issues of course. There’s other tests that a neurologic surgeon can obtain to evaluate the degree of potential reflux or incontinence. And that’s something that can be discussed in severe cases of course.

Expect No Secretions When Orgasming Post-Vaginoplasty

Erin Everett: Okay. Excellent, well thank you for that … I have another question that a patient had emailed in about orgasm post vaginoplasty. I know we touched on sexual function and whatnot. Their question pertains to should I expect to ejaculate from my new vagina.

Gabriel Del Corral: Technically no because the ejaculatory orgasm that occurred before, it’s really not possible at this time. It’s a different kind of orgasm. I tell my patients you really have to sort of explore, again, boys versus toys at that point. And kind of get in that exploration mode to see, because it is a different kind of orgasm. A lot of patients describe it as being significantly a mental part of the procedure. Very different than the typical ejaculatory orgasm that patients may used to have of course.

Erin Everett: Okay. So they shouldn’t expect any kind of secretary fluid with their orgasms?

Gabriel Del Corral: Correct.

Erin Everett: Okay, well that’s good to know. And I also tell my patients too, a lot of that has to do with testosterone levels. And the gonads are now removed, so regardless of how well I’m doing blocking your T, now you’re not making any.

Gabriel Del Corral: Exactly. There may not be anything in the seminal vesicles, they may be completely dry based on hormone therapy. Yeah.

Erin Everett: Yep, yep, yep. Excellent. Well that’s awesome, thank you so much for all that information.

Gabriel Del Corral: Yeah of course.

Erin Everett: As far as my questions go, I feel like I touched on everything. Did you have anything that you wanted to make sure that listeners were aware of, or any frequently asked questions that you get that you would like to address?

Closing Remarks on Gender Affirming Surgery

Researching Gender Affirming Surgeons

Gabriel Del Corral: Yeah I just want to give a general comment about making sure that patients are really knowledgeable and really research their options before going into a specific procedure. I think that a lot of the providers, the majority of the providers that are doing gender affirming surgery have been doing it for a long time and have operated on a number of patients. But it’s important for patients to really do their research, understand the provider, and really there’s nothing wrong in seeing more than one surgeon and sort of get a feel for that person. Because the person you decided to go with is the same surgeon that is going to need to be with you by your side for the next could be several years of the process. You really want to make sure that you really connect that person and that person is available for you.

Individualized Care

Erin Everett: I think that’s amazing remarks. Just from our brief interactions, I can tell that your approach to patients is very different than a lot of people. Less transactional and much more focused on developing a relationship. And I think amongst community members, that speaks volumes. For a community that’s often afraid that they will take a chance, take a lunge on the wrong provider, and they’re the ones who are left dealing with the consequences and sacrifices of that decision. So to know that they could develop a good relationship with a surgeon who’s willing to stand by their side during years of recovery speaks volumes. Because a lot of other surgeons aren’t necessarily developing those relationships. And I think that’s so important with these people. That’s my approach to care. I tell them all that. I practice very individualized medicine, and what looks good for you is going to look good for somebody different, but the entire way we’re going to be customizing and I’ll be right here the entire time. And a lot of patients take comfort in that. So I appreciate you saying that.

Gabriel Del Corral: Oh well thank you very much. I think it’s key to make sure like you said, individualized care. It’s really important for our patients because it’s really a diverse world nowadays. And really we got to make sure that we do our best. And there is going to be … there’s so much access to information very rapidly available. But at the same time we want to make sure that our patients are getting the care and attention that they need as well.

Erin Everett: Right. Which a lot of people do focus on volume and numbers. And are looking for surgeons who are cranking out cases. I think there’s a lot more to be said about someone who’s maintaining a volume at a level that they can manage and make sure that their post operative patients are being well taken care of, and aren’t necessarily advertising on popular social media platforms like TikTok and such.

Gabriel Del Corral: Yeah I agree. We were talking about this. I think there is a balance. I think volume, it is important because that is certainly a level of experience also.

Erin Everett: Yeah.

Gabriel Del Corral: But also there’s going to be other parameters as well such as the ability to research and innovation. And really the actual university or academic place or wherever hospital you decided to go to is going to be equipped to handle whatever complications they may develop from that surgery, so that’s important as well.

Erin Everett: Absolutely. Well thank you so much for your time. I have thoroughly enjoyed speaking with you today. And how can our patients and listeners get in touch with you? What’s the best way that you want them to reach out to you?

Gabriel Del Corral: Thank you so much for the invitation. It’s been really an honor. The best way to reach out to us is my website is www.DrDelCorral.com. You send a message through there and it goes directly into my email and I’ll put you in contact with the right person in my office and we can discuss further.

Erin Everett: Yeah. And I can attest to that because that’s how I first reached out to you and you were really responsive. I love it.

Gabriel Del Corral: Absolutely.

Contacting Dr. Gabriel Del Corral

Erin Everett: Yeah, absolutely. Okay. We’ll also include all that information at the end of our podcast notes. Listeners can expect to be able to reach out and we’ll have all kinds of contact information and information about Dr. Del Corral’s procedures and also ways to look at pictures of things that he’s done, which he does have posted on his website for anybody who is curious and wanting to actual visualize the procedures that he’s doing.

Gabriel Del Corral: Yeah absolutely. Thank you so much Erin for the invitation. And I’m so happy that there is people like you really bringing the right information to patients and really unbiased information for patients. And I think that’s what we need nowadays in a world with a lot of media diversity and information I think it’s important.

Erin Everett: Yeah.

Gabriel Del Corral: The mission that you have accomplished, so congrats.

Erin Everett: Thank you so much for saying that. I just try, you know, to work with advocates like yourself as well to get the information out there so the people who don’t have good access to good care and information can. I hope that it reaches the people that need to hear it. I appreciate your sentiments on that.

Erin Everett: Remember everybody, stay fierce and live your truth …