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Episode 24 Transcript

An Individualized Approach to Gender Affirming Surgery with Dr. Sidhbh Gallagher

Introducing Dr. Sidhbh Gallagher

Erin Everett: Hey, everybody. Welcome back to Exclusively Inclusive. I’m your host Erin Everett, nurse practitioner. On today’s episode, we’re going to be interviewing very special guest, Dr. Sidhbh Gallagher. Dr. Gallagher is a double board-certified surgeon in both general and plastic surgery. She has her own practice in Miami, Florida called Gallagher Plastic Surgery. She does offer all kinds of plastic surgery and cosmetic elective procedures with a special emphasis on gender affirmation. With her background in academics, Dr. Gallagher always seeks to combine her artistic flair with the latest cutting-edge techniques to bring an outstanding natural result to her patient.

Erin Everett: Originally from Ireland, Dr. Gallagher earned her medical degree from University College in Dublin, where she graduated in the top 3% of her class, which after speaking with her was literally no surprise this woman is brilliant. After graduation, she decided to move to the United States to seek some world-class training. Then she completed eight more years of intensive surgical training. Dr. Gallagher served as an assistant professor at Indiana University from 2015 to 2020, where she researched and developed new techniques such as Masculoplasty. We’re going to be talking a lot about Masculoplasty today actually. We’re also going to be talking about the special surgical techniques that she uses that allows people to go home without drains.

Erin Everett: Dr. Gallagher is a leader in the field of gender affirmation surgery. She has founded both the Eskenazi Health Transgender Health and Wellness Program, as well as the program at Indiana University Health. In 2020, Dr. Gallagher established her private practice in Miami. When Dr. Gallagher meets her new patients, she combines her aesthetic sense and surgical experience to evaluate them. This allows the patient an individualized treatment plan and ensures enhancement of the patient’s own natural features. Her patient-centered approach is her secret to avoiding the operated on or cookie cutter look as she puts it, which is funny that she does describe it as the cookie cutter look as I often tell my patients all the time that I don’t practice cookie cutter medicine.

Erin Everett: She’s a very innovative plastic surgeon. She offers her patients the latest advancements and techniques. She’s traveled extensively to learn techniques, which she has also brought back to her practice in addition to her own techniques that she’s developed to better serve patients. Those are the techniques that we’re going to talk about in detail today. Gallagher Plastic Surgery embodies Dr. Gallagher’s world-class standards of care and excellence delivered in a patient-focused, warm, and friendly setting. Along with her sister Neasa, Dr. Gallagher has designed every detail of her practice with the goal of delivering the best possible patient experience combined with outstanding results.

Erin Everett: I have no doubt that you guys are going to really enjoy speaking with Dr. Gallagher today. The best thing you could do after this episode if you’re thinking about getting surgery, particularly if you’re falling somewhere in the gender spectrum and identify as non-binary, is sitting down having a conversation with her. She’s going to do her best to meet you exactly where you’re at. Without further ado, please welcome Dr. Sidhbh Gallagher. All right. Welcome to the show, Dr. Gallagher. We’re so happy to have you.

Sidhbh Gallagher: Thank you for having me.

Erin Everett: Of course.

Sidhbh Gallagher: Thank you.

Erin Everett: Before we get started, would you go ahead and let our listeners know what your pronouns are and just maybe a little fun fact about you or hobby?

Sidhbh Gallagher: Sure. My name is Sidhbh Gallagher. Pronouns, she, her, hers. I guess fun fact, probably one of the things I get asked a lot is my accent. I’m Irish born and raised. Yeah. I guess that would be the fun fact for now.

Erin Everett: Yeah. Excellent. That is a fun fact. I love your accent. I have a lot of remote family, I haven’t met most of them, but they’re all from Northern Ireland, in Belfast area. When you told me that you’re from Dundalk, I looked it up. That’s near the border, right?

Sidhbh Gallagher: It’s very close, yeah. I was born and raised three miles south of the border.

Erin Everett: Oh, cool.

Sidhbh Gallagher: My accent will be considered pretty Northern. One other thing I noticed is you haven’t pronounced the second G in Gallagher. Nobody knows that.

Erin Everett: Yeah, yeah.

Sidhbh Gallagher: Definitely, there’s the Irish connection there.

Erin Everett: Yeah. Most people say it wrong, right?

Sidhbh Gallagher: Exactly.

Erin Everett: Yeah, my maiden name is McGoldrick. You can imagine the amount of confusion that people would get with that. It’s like McGoldrich, McGoldrach.

Sidhbh Gallagher: Oh, for sure. Yeah. Yup. Yeah.

Erin Everett: Yeah, it’s funny. Cool. One of the reasons why we wanted to have you on the show is because you offer such an amazing service to the trans community with the surgeries. I was looking at your website, you have a lot of different options for both the feminization and masculinization process, which I find really unique and awesome.

Sidhbh Gallagher: Yeah, yeah. I think one of the things I always say is my patients have been my best teachers. When I got into this field years ago, I was coming from a surgical background where if you need your appendix out, you get an appendectomy. There’s one size fits all. Of course, we understand now that humans are very diverse creatures. My patients have really taught me that. We really have to individualize what is going to be affirming to that individual. Of course, 20% to 30% of my patients identify as non-binary. What I strive to offer in my practice is just a range of different things that patients can be educated on and then, hopefully, we can find the solution that’s most appropriate for them if they need surgery at all because, mostly, surgery is not for everybody.

Erin Everett: Right, right. Of course. If someone’s not seeking surgery, they’re probably not reaching out, right?

Sidhbh Gallagher: Yeah, absolutely.

Erin Everett: By the time they land in your lap, the fact that you’re doing such patient-centered, individualized care is really unique because a lot of, I think, in general, providers … Some of the providers I’ve had on the show are definitely much like yourself and do provide patient-centered care, but I still wouldn’t think it’s common to come by. I think a lot of people do practice what I like to call cookie cutter medicine. It’s refreshing to find other providers that don’t do that.

Sidhbh Gallagher: Yeah, yeah. Definitely, it’s a deficit that’s there. The medical profession, particularly the medical profession in the United States, we’ve been a little bit behind. We’re catching up, we’re trying to figure this stuff out. Still, it can be very difficult, particularly it’s a binary world out there, really, in the medical profession still.

Sidhbh Gallagher: Several times a year, for example, I will see patients who have had top surgery elsewhere and the surgeon they we’re dealing with insisted that, let’s say, their nipples were put back on again when they’re clearly saying, “This is not affirming to me and this is not what I want,” but for whatever reason, that surgeon thinks, “Well, no, this is what’s top surgery.” Then we end up removing the nipples, which is a very simple procedure but, again, it just speaks to there’s a lack of understanding there amongst the medical community. It’s improving all the time, but we have a ways to go.

Erin Everett: Yeah. Yeah, I would agree with that. When you’re talking about the nipple procedures and everything, too, I guess I have a question about that because I know other surgeons do it differently as well. When you are replacing the nipples for people who do want to keep them, are you keeping any breast tissue?

Sidhbh Gallagher: Typically, the main two procedures I’ll do for top surgery would be the classic double incision, or my version of that is Masculoplasty. Then the other, for smaller chested individuals, we’re usually doing keyhole or a minimally invasive procedure where we’re just making the incision in the nipple itself. Again, there’s a range of other procedures we can do in between breast reduction type stuff, where we’ll keep a variable amount of breast tissue. By and large, the patient tells me how much breast tissue they want left behind.

Sidhbh Gallagher: With regards to nipple, there’s a few different ways of recreating that nipple or preserving that nipple, and we could get quite technical talking about this. There’s a way you can keep a nipple on a stalk or what we call a pedicle, or the more common way would be to take it off, completely redesign it, reshape it, and put it back on the chest. I would say the majority of my top surgery patients, for their goals, I’m often asked for a masculinized chest. Usually, in order to achieve that, we would take the nipple off completely and replace it. That’s called a free nipple graft. It is possible, and it depends on the size of the breast to begin with, to keep it on a pedicle. I get asked to do that a few times a year. That will be usually individuals who are really concerned about sensation.

Erin Everett: Okay. That’s what I was going to ask you, if that was the main difference there.

Sidhbh Gallagher: That would be the main difference we do that. Usually, we’re able to get the chest pretty flat as long as we’re starting out with maybe a B or small C cup to begin with. Of course, the problem is not many trans men, for example, wore bras so the cup size thing can get very … I tried to stay away from that because it can be confusing for folks. Usually, that’s the patients who request me to do that. In my patient population that we’ve chosen to do the pedicle route, we have been able to get them quite flat and they have been able to keep sensation, but that’s not the rule. There’s no guarantee you’ll be able to keep sensation, unfortunately, with any of the techniques.

Sidhbh Gallagher: One thing I’ll tell you that’s interesting about the free nipple graft, when it comes off completely and goes back on again, before I was doing these surgeries, I always thought, “Well, that nipple will be numbed for life,” but we’re actually seeing that’s not true. Sensation does come back. It may not be as sensitive as it was to begin with, but we know there’s one study out of Germany where they had what patients described as good sensation. 80% of patients had what they described as good sensation one year after surgery. With any of these surgeries, you typically don’t have large areas of numbness permanently. It can take a long time for the nerves to march back in again, but we’re usually not talking about permanent numbness. Once the nipple graft goes well, oftentimes, your nips will act pretty normally and get hard when it gets cold.

Erin Everett: Yeah. Yeah. The body is an amazing thing. I’m sure the peripheral nerves do restore what you’re saying to some extent.

Sidhbh Gallagher: Yeah. Exactly. Yeah.

Erin Everett: That’s really cool, because I think a lot of people feel like what you’re saying is they have to decide and be expected to not have sensations. There’s a little bit hope there then.

Sidhbh Gallagher: Yeah, absolutely. Yeah.

Erin Everett: Awesome. One of the other things I wanted to make sure we touch on today is I have had other affirming surgeons on the show and most deal with vaginoplasty, so I really wanted to talk to you, too, about your procedures for metoidioplasty and phalloplasty and what that looks like for patients, like insurance coverage and that kind of thing.

Sidhbh Gallagher: Yeah, yeah. Absolutely. Meta versus phallo, unfortunately, it’s one of those things there’s not a great solution for either, because with all of the procedures, there are compromises. What we have to do, a lot of education has to be done with each individual patient. You really have to sit down and navigate the patient’s goals. If we can get a hierarchy of the patient’s goals, that’s awesome to figure out which procedure would fit the best.

Sidhbh Gallagher: Then there’s other limitations such as the patient’s body type, their BMI, that sort of thing, what procedure is going to do well for the certain factors such as growth, bottom growth, whether much of that has happened or not. Typically, whenever I talk about bottom surgery for transmasculine people, we can break them down into two main categories. That would be meta, where we’re using the patient’s own tissue or bottom growth down there. We’re maximizing it and we’re using it to create the male parts.

Sidhbh Gallagher: There’s a bunch of different maneuvers we do to the anatomy down there to help bring it front and center usually is what we’re doing. It just depends on the individual patient, what we’ll do. Typically, what we’ll do is release some ligaments that allow things to stand up more. We may do what’s called a mons lift to bring things more forward and expose the growth a little bit more. How we deal with the other anatomy down there, it’s possible to do a vaginectomy where we remove the vagina. Of course, you need to have a hysterectomy to do that. You can then do a scrotoplasty to create a scrotum and then possibly do testicular implants.

Sidhbh Gallagher: Again, a lot of these different steps are optional. Then, of course, there’s the question, do we add in urethral lengthening and a stand to pee procedure or not? What I would say is it’s so important, education, because there’s a lot of myths out there, a lot of confusion, and a lot of patients don’t understand what their options are. I’m a plastic surgeon. I’m not a urologist, I’m not a plumber. Right now, unfortunately, here in Miami, I don’t have a plumber so we don’t do the stand to pee options.

Sidhbh Gallagher: What we do is, typically, my patients who are opting for meta are doing all those other procedures to enhance and bring forward the bottom growth that they have, but they’re still going to pee from where they always pee. That works quite well, whether or not we’re doing the scrotoplasty or the testicular implants or anything else. That’s meta. The major downside patients find with meta is you’re always going to be limited in size because you’re working with the anatomy you have down there. Typically, as an idea, the erect penis will probably get thumb size at best, depending on how much growth you’ve had down there. That’s meta.

Sidhbh Gallagher: Then we shift over to the other thing, which is phalloplasty. Phalloplasty just means creating the male parts but never going to bring in tissue from elsewhere in the body in order to create it. This is where it can get so confusing for patients because there are so many different places you can bring this tissue in from. The more common ways would be to bring it in from the arm, the forearm. We can bring it from the belly. We can bring it from the thigh. We can bring it from the lower leg. We can bring it from the back.

Erin Everett: Oh, wow. I didn’t realize that.

Sidhbh Gallagher: Yeah. It’s just you have to tailor to the individual patient. With each of the places you’re taking it from, there are downsides and upsides. If we want to focus on … Maybe one of the more common ways traditionally of doing it was creating the male parts from the forearm, and so many people look at that and say, “What? How is that a good way to make it?” I remember that’s what I thought the first time I saw it.

Sidhbh Gallagher: The advantage of taking it from the arm is you’re able to roll a tube within a tube. Again, you’re serving that stand to pee function. Then the other advantage of it is there’s a healthy supply of nerves to that tissue of the forearms, the medial and lateral antebrachial cutaneous nerves, which could be potentially hooked up to the nerves down below so that it may be going to be possible to grow erogenous sensation into the male parts. That was one of the reasons it was traditionally done.

Sidhbh Gallagher: Again, the major downside of taking tissue from the arm is going to be the scar, because it’s a pretty obvious scar and you have to take a skin graft from the leg to cover the scar, so lots of scars, lots of what we call donor site morbidity. That’s why some patients will opt for the thigh or the belly or there’s, like I said, the back, the lower leg. There’s lots of different options.

Sidhbh Gallagher: With phalloplasty, there are a number of different stages you can do because it’s difficult, it’s a complex thing and a many stage thing. When we talk about stages, I mean number of operations. What oftentimes we have to do is create the male parts first, then possibly come back to what’s called a glansplasty to make it look a little bit more natural. Then for erections, we have to put in a device for the patient to be able to have erections. Then if you want to do the plumbing, there’s oftentimes a number of different steps towards stand to pee. They’re complex surgeries.

Sidhbh Gallagher: For this reason, amongst my patients, the fellow plasty folks will always go through insurance pretty much. What the only exception would be when we create it from the belly, we can do an abdo phallo. The first part of that procedure, that is pretty affordable. We’re able to do that if their insurance doesn’t cover it. The reason patients like that is because when we use the tissue from the belly, the donor site or where we’re taking that tissue, we’re able to do a tummy tuck. A lot of folks like that one. It’s one of the best scars. When it comes to all the other types, because they’re long and complex procedures that oftentimes will require at least a few days in the hospital, that’s usually when we have to get insurance coverage because it becomes tens of thousands once we’re talking about days in the hospital. It gets pretty expensive.

Sidhbh Gallagher: Meta can often be done out of pocket because, depending on the complexity and how many bells and whistles we want to do, that could be out of pocket as it’s not much more expensive than top surgery, and same thing for abdo phallo. All the other options, pretty much we have to get insurance involved. Then, of course, as you know, most insurance companies, it gets confusing because there’s a number of different steps or I should say there’s a number … It depends on the patient’s individual policy what the requirements will be. If that patient had to provide one, two, three, four letters, whatever it is, we have to look at that individual policy.

Erin Everett: Yeah, yeah. Yeah, that’s what I try to explain to people, too. If they do get frustrated with the amount of letters they have to get, I’m like, “It’s your insurance dictating that most of the time, not the surgeon, for coverage.” I do have a couple of questions. I noted when going over your information, which I found really easy to read on your website, I found that probably a lot of patients, the way that you have it laid out is very easy to understand, which I liked. You did mention on here that sometimes with metoidioplasty, you get better results if they’ve been on testosterone for two years. Is that to get the optimal bottom growth?

Sidhbh Gallagher: Exactly, exactly. Yeah, because we know certain changes that can be very frustrating for patients when they’re starting on testosterone because it’s months, even years for some of the changes rather, certainly not weeks. One of the slower things to come in is going to be that bottom growth. We always say in plastic surgery, you never want to operate on a moving target, whether it’s if you’re losing weight, or you’re having bottom growth, or you’re having top growth if you start on feminizing hormones. We always want you to be in a steady state because we want to get the best results we can. If there’s more growth going to happen or change, we got to wait for that. That’s one of the times that rule applies. We want to maximize the bottom growth, so that’s usually about two years.

Erin Everett: Okay. Sometimes I have patients who ask for topical testosterone for that area. I have done that before just to enhance bottom growth. Is that something that you ever recommend to your patients who might be feeling frustrated with lack of tissue growth, or have you encountered that at all?

Sidhbh Gallagher: Yeah. My experience with that is I believe it works. There’s not great literature specifically for these patients that have used it for other urological conditions that it has been successful. What I’m finding recently, the most recent times we prescribed it, it’s you have to find a compounding pharmacy. Basically, what I’m saying is it’s very difficult to find. A few months ago, I remember posting somewhere and saying, “Can anybody in the community direct me to a compounding pharmacy that’s doing this?” We didn’t get any results.

Erin Everett: Oh, really? I can definitely give you some connections for that.

Sidhbh Gallagher: Awesome. Yeah.

Erin Everett: They do do mail order now. They’re not going to necessarily be in the Miami area but they will ship. Yeah. I usually prescribe it as a 1% compounded cream. It’s usually fairly affordable because it lasts a long time. Yeah, it is good. Again, I think that it works but, again, it’s all anecdotal, right?

Sidhbh Gallagher: Right.

Erin Everett: Because nobody’s really directly studied it.

Sidhbh Gallagher: Exactly.

Erin Everett: But I have had positive results with it. That’s cool. The other thing I was going to ask you then as it pertains to sometimes being on hormones longer helps surgical outcomes was I get a lot of questions from either patients who identify as non-binary but assigned female at birth and also transmasculine, “Do I have to be on testosterone for a year to get top surgery?” I definitely have patients that establish care with me to start hormones, and they’ve already had top surgery. I typically tell them like, “Surgically, I’m not sure what’s the benefit there in either direction but I know that, basically, it depends on your insurance and the surgeon.” Do you have any weigh in on that on whether you get better results surgically?

Sidhbh Gallagher: I do. Yeah. Yeah. Certainly, 20% to 30% of my patients, I do top surgery on that are not on testosterone, have no need for testosterone, maybe will take it in the future. What I will tell you is there is a myth out there that your breast tissue would grow back if you were to start on testosterone. There’s no evidence that that’s true. I’ve never seen that happen. You don’t necessarily have to wait. However, what testosterone will do is it will atrophy or shrink the breast tissue somewhat. There’s a small group of patients that I think it’s worthwhile doing some time on testosterone. We have that conversation before we start it.

Sidhbh Gallagher: The first group of patients will be those who have very small chest to begin with, because if there really is not much tissue there, “Well, hey, maybe we’ll get lucky and the testosterone will do its job and shrink that down and you may never need surgery, so that would be awesome.” That’s the first group. Then the second group I think it’s interesting in is the group that are borderline, that have small breasts. Again, not to talk about cup size too much because, again, it could be pretty useless, but to give you an idea, we’re really on small B or on A cup.

Sidhbh Gallagher: In those patients who have small chests who’ve never been on testosterone and plan to take testosterone, oftentimes, we’ll say, “Well, why don’t we just see how much shrinkage we get?” Because those patients, we’re trying to decide between are we going to do a double incision or we’re going to do a keyhole. Maybe they’ll get some shrinkage from the testosterone and now, they’ll be a better candidate for keyhole surgery. Those are the only two times we’ll say pause, we’ll wait. Again, I like patients to be as involved as possible with this decision-making because, again, in that small-chested individual, sure, the breast tissue may shrink but the skin may not shrink so we may well end up doing a double incision in the first place. Yeah. For that reason-

Erin Everett: Yeah. That’s what I was curious about, too, if it impact the skin elasticity and all that stuff and whether or not you’d still have to end up cutting a lot of extra tissue out.

Sidhbh Gallagher: Yeah. Oftentimes because, of course, the keyhole surgery does nothing to get rid of excess skin, so oftentimes in those cases, if there is excess skin, the breast tissue atrophies but the skin is left behind so we’re still doing a double incision. Yeah, yeah. That would be typical.

Erin Everett: Yeah, that makes sense.

Sidhbh Gallagher: Yeah. I’ve probably gotten a little cynical over the years but, otherwise, when I see insurance companies mandating one year in testosterone, I feel like it’s oftentimes just another barrier to care and, of course, it’s a complete disregard for individuals who don’t want or need testosterone as part of their transition.

Erin Everett: Oh, 100%. I couldn’t agree more. Yeah. Honestly, I think it goes back to just being ignorant and misinformed on the community, other people who are making those decisions on the parameters and when it should be covered.

Sidhbh Gallagher: Right, right.

Erin Everett: Yeah. That probably leads me to believe that if someone is paying out of pocket, you don’t require a certain timeframe or what are your requirements as far as letters and stuff go.

Sidhbh Gallagher: Okay. The more I get into this field, the more of an informed consent model we’re beginning to apply, and I think that’s across the board. Initially, when I started in this field, I was sticking to WPATH guidelines, but the version seven we have, maybe a lot of folks would agree who work in this space, are maybe a little bit outdated. It would be interesting to see what the next version shows. For that reason, the requirements really aren’t that much. Obviously, for minors and younger individuals, we’re going to need mental health, obviously, to be involved. Other than that, it’s just a conversation with each individual or patient and make sure they’re able to consent and they’re fully informed.

Erin Everett: Yeah, yeah. No, I agree with that model, informed consent. I think it reduces barriers to care majorly. The other thing I wanted to ask you, too, you have on your website, you talk about the Masculoplasty procedures. When you’re using that term, is that encompassing just the top surgery with the contouring or is there something else that comes with that?

Sidhbh Gallagher: Yeah. My version of top surgery, really what Masculoplasty for me means, and that was just a name we came up with because what we wanted to emphasize-

Erin Everett: I like it, yeah.

Sidhbh Gallagher: Yeah. We want to emphasize it’s not just a mastectomy, it’s a chest masculinization. There’s a bunch of nuanced things we do in that surgically. One thing I’m very passionate about, and I’ve published on a couple of times, is doing it drain-free. That’s the main difference with my technique, is that I never put a drain in. It’s nuanced but there’s a bunch of spin-off benefits. Actually, when we published and looked at the data, it does lead to lower rates of complications after surgery.

Erin Everett: Really?

Sidhbh Gallagher: Yeah. Yeah, so lower rates. The bane of top surgery is what we call hematoma or bleeding. It does statistically significantly drop that chance way down. It also drops down the chance of getting a fluid collection in there. Just to explain what the difference is is really very simple. Back in the day, maybe seven years ago, when I would do a mastectomy and remove the tissue, pull the skin edges together and you’re left with a space behind, and the human body doesn’t do very well when there’s spaces underneath the skin.

Sidhbh Gallagher: What it does is it tries to fill that space with fluid. In order to deal with that fluid, a little drain, a plastic tube will be placed in through the skin and would hang out of the skin for about a week, sometimes maybe two weeks, to get rid of that excess fluid. Patients, in my experience, would have quite a bit of discomfort with the drains, it caused some anxiety, and just, basically, patients don’t like drains.

Sidhbh Gallagher: One of the things when I started doing this more frequently, like five years ago, I started doing the drain-free technique. Basically, all you do is now when you remove the breast tissue, rather just pull the skin edges together and leave that dead space, you use dissolvable stitches on the inside to quilt down that dead space. Nothing looks different from the outside. You can’t see that there’s any difference from the outside, but you’ve taken 10 to 15 minutes extra to eliminate that dead space. What it does, the benefits, obviously, the concrete benefits, we never have to use a drain. Also, we don’t get fluid collections. Probably 800-plus, we’ve never gotten one. Then the really cool thing we noticed was that because that potential space isn’t left behind, patients seemed to bleed a lot less.

Erin Everett: Oh, that’s awesome.

Sidhbh Gallagher: Yeah, yeah. Those are the benefits.

Erin Everett: That’s really cool because I think, too, people get nervous about how they’re going to manage their drains postoperatively, too, because these are lay people. Maybe their first time ever having a surgical procedure being admitted into a hospital or anything like that, so it’s nerve-racking going home strapped up with some drains and worrying are you going to pull them out too soon. I think it’s awesome.

Sidhbh Gallagher: Yeah. I used to teach other plastic surgeons at my previous job, and that was the one thing, I was like the drain-free person. I used to say things … I stole this quote from a famous surgeon, Howard Kelly. He used to say drain is a confession of an incomplete surgery. My residents would know me, I’d be like, “Close that dead space, do not leave it.” It’s a technique. The surgeon needs to know how to do it. It’s not very complex but, hopefully in the future, we’re going to see more and more surgeons doing it because I believe that we have the data to back it up. It’s a better procedure, has lower morbidity, and the patient could shower right away and we’ve taken out all that anxiety and it seems to drop pain scores as well.

Erin Everett: Yeah, I bet. That’s awesome. The other thing I like about how you’ve coined the term Masculoplasty is it does have a masculine spin on it, so people don’t have to walk around talking about mastectomy which is famously feminine.

Sidhbh Gallagher: Exactly. Yeah, yeah.

Erin Everett: I think that’s also really considerate of the community that you’re serving.

Sidhbh Gallagher: Yeah, yeah.

Erin Everett: Yeah, that’s cool. What is your favorite procedure to do out of all the ones that you do?

Sidhbh Gallagher: Oh, it’s probably going to be vaginoplasty, probably.

Erin Everett: Oh, really?

Sidhbh Gallagher: Yeah. It goes back and forth. I like doing creative things. Plastic surgery is awesome because you get to come up with lots of different ways of doing things. No two procedures are ever the same.

Erin Everett: It’s artistic.

Sidhbh Gallagher: Yeah, yeah. Absolutely. Usually, meta lays for some creativity as well. I think probably vaginoplasty because no two sets of genitalia are identical. Oftentimes, which most patients, my briefing will be give me the most natural appearance possible, so how to create that organic and usually to bring the external genitalia into looking as natural as possible. Yeah, I love doing those procedures. Again, like Masculoplasties, I love those, too, so yeah.

Erin Everett: Yeah. It just sounds like you just love what you do in general.

Sidhbh Gallagher: I do. I do.

Erin Everett: Yeah, that’s awesome. Yeah.

Sidhbh Gallagher: Yeah, yeah, yeah. No, it’s great. It’s one of those things I always suspected that operating would be like … I used to love drawing and painting as a kid and I would get into that state of flow people talk about, forget to eat, forget to go to the bathroom, whatever, and I always hoped surgery was going to be like that, and it is. It’s awesome.

Erin Everett: Yeah, that’s good. When you’re talking about vaginoplasty, I know on your site, you have, basically, two major different types with the penile inversion but also the zero depth. Which would you say is the most popular that people come to you for?

Sidhbh Gallagher: About 20% of my patients choose zero depth, and that’s maybe a little bit higher than usual just because, again, I made videos about it and published on it. For that reason, I probably see a higher amount of patients. Zero depth is a great procedure for the community to be educated on because for the patient, probably the most difficult part of bottom surgery is the creation of a vaginal canal because of the maintenance that’s involved, because it’s really a commitment. The patient is always going to have to dilate, and it doesn’t matter what we were going to … Now you see the peritoneal vaginoplasty and a bunch of different mirror ways of creating that vaginal canal. The unfortunate news is none of those as yet have been proven to be dilation-free techniques. The patient always has to do maintenance.

Sidhbh Gallagher: Then, of course, the worst complications that could happen all come from the vaginal canal. For transfeminine or non-binary patient who is never going to use that vaginal canal, why would they go through all the hardship of having a more morbid surgery and all the dilation to go with it? That’s why zero depth is a fabulous procedure for quite a few patients because it feminizes everything on the outside. From the outside, you can’t tell if there’s a vaginal canal or not, but they don’t have to do the maintenance and they don’t have to risk. It’s a much lower risk procedure.

Sidhbh Gallagher: For that reason, it’s very nice and it’s good because, typically, the patients who will come to me for that procedure, they’re like, “I didn’t even know that was an option.” That’s oftentimes what they’ll say, “And then I saw your YouTube video,” and that’s how they end up with me. Again, it’s harping back to the fact that when it’s patient-centered care, the patient has to be educated on the options in order to choose. Yeah.

Erin Everett: Right, right, right, so they can make an informed decision about what works best for them. Yeah. I’ve asked other surgeons this and I know it’s just now becoming more talked about, but other non-binary options would be like penile-sparing vaginoplasty or just total, basically, removal of all the external genitals. Those are the two options. Have you ever done those procedures or shown interest in doing those procedures?

Sidhbh Gallagher: Yeah. I haven’t done nullification. I think that’s the other term for where we just remove everything. I haven’t done that. It’s something I’m interested in. It’s something I’d have to collaborate with the mental health professionals, because it does take away erogenous sensation and maybe it probably takes away the ability to orgasm. That, just for me, again, and I’m coming into this field as a straight, cisgender woman, I’ve had so much education and, again, that’s something I have concerns about. I haven’t done it personally. I don’t think any of my mentors have done it that I know of, but that’s something I would need to be educated on more, like what the goals were for that individual and what the motivations were because, quite honestly, I don’t quite understand where that patient’s needs will be coming from.

Sidhbh Gallagher: Again, my patients have taught me to have an open mind, so I would need to be educated on that. With regards to the other non-binary procedures, it really comes down to me when I talk to a patient. For example, I had a patient recently who didn’t want to do … She identified as transfeminine but she didn’t want to do penile-sparing. Her goal was to essentially appear like a transmasculine patient who had undergone a bottom growth, so a large clitoris per se. That sort of thing, that’s technically easy to do. In those situations, it’s a discussion with the patient to really try and understand the goals as well as possible and can we do it and can we do it safely.

Erin Everett: Yeah. That’s good. Yeah, I hadn’t thought about that, just reducing the size of the phallus to look more like a meta.

Sidhbh Gallagher: Yeah, yeah, yeah. Yeah, I have had that request. Again, my practice philosophy over the years, what I find serves my patients best, I know this sounds very obvious, but is really trying to understand what the patient’s goal is and setting aside my biases and my preferences and trying to help them get to that goal. It’s never bitten me. Those patients do well. They’re very happy. These are very well-thought-out decisions. Within reason, as long as we’re not doing harm, it’s worked out very well. Rather than taking that paternalistic approach and saying, “Doctor knows best,” I think the medical professionals are slowly beginning to realize, “No, patient knows best.”

Erin Everett: Right, especially when it comes to their gender expression. I’m sure for other types of surgeries, like if you’re talking about hemicolectomies and things like that, doctor knows best.

Sidhbh Gallagher: Absolutely, yeah.

Erin Everett: But not when it comes to their gender expression. It’s such a unique population that you serve. A lot of the surgeons that I have talked to, the reason why I bring them on the show is because they’re just like you. They listen to their patients, they try to provide individualized care but, again, I still don’t think that’s the norm. It’s very unique, like you’re a unicorn for doing those things.

Sidhbh Gallagher: Wow. Thank you.

Erin Everett: Yeah. Yeah. No, it’s very exciting.

Sidhbh Gallagher: Again, it’s just you do what works. Time and time again, it’s been reinforced to me that this is what works, so that’s what we do.

Erin Everett: Yeah. Right. For you, it makes total sense. It’s like, “Well, why wouldn’t you do it this way?”

Sidhbh Gallagher: Yeah, absolutely.

Erin Everett: Not everybody thinks the same way.

Sidhbh Gallagher: Yeah, yup.

Erin Everett: I guess I should have asked you this earlier, but I’m really curious how you landed in Miami.

Sidhbh Gallagher: Yeah. I’m Irish, obviously, born and raised. I just practiced for one year in Dublin as an intern and I realized back then, that was 15, 16 years ago, that it was still like an old boys’ club. Really, my surgical career would be maybe negatively affected by that. For that reason, I went to Philadelphia, did general surgery in Philadelphia for five years but always wanted to do plastics. Got into plastics in Indianapolis in Indiana and I did my three years of plastics there. Towards the end of that training, I became exposed to gender affirmation surgery and then subsequently did my own fellowship because there were no fellowships back then. I traveled to Serbia, Australia, Belgium.

Erin Everett: Oh, cool.

Sidhbh Gallagher: A few different places, picked up the skills and then came back to Indiana and I was able to set up a program there where I was for five years.

Erin Everett: That was part of Eskenazi Health?

Sidhbh Gallagher: Exactly. Yeah, yeah. Eskenazi is the county hospital there. It was all part of the same program. We were able to build it up and it worked out really well, but I began to understand my own personality better over the years. I’m not a good employee and I have real problems with authority, especially when it comes to patient care because I have ideas about how it should be, and if anybody tries to interfere with that, it doesn’t go too well. Basically, I realized private practice was definitely the way for me. I grew up by the seaside in Ireland, and even though that looks nothing like here in Miami, I’ve always loved the ocean. Miami was an obvious choice.

Erin Everett: A much warmer version.

Sidhbh Gallagher: Yeah, yeah, yeah. I felt like I don’t want to tell you but you know… I love the diversity down here. It’s been awesome so far, so yeah.

Erin Everett: Yeah, I haven’t actually had a trip to Miami. I’ll have to but I have heard it’s very culturally diverse there.

Sidhbh Gallagher: It is. It is. It’s hard to walk down the street and hear English.

Erin Everett: Yeah, that’s awesome.

Sidhbh Gallagher: It’s like every other language in between. Yeah, I love it.

Erin Everett: Yeah, that’s great. I know that your sister Neasa, is that how you pronounce her name?

Sidhbh Gallagher: Yup, Neasa. Exactly.

Erin Everett: Yeah. I think that’s so awesome that you guys started that practice together. That’s so special.

Sidhbh Gallagher: Yeah, yeah. Yeah, she’s seven years younger. She’s my sister, seven years younger. It’s really awesome because years ago, she was always an intense advocate, but she was a school teacher so she subsequently became a school principal in the Middle East. Wicked, smart girl but she was always under-challenged I felt like or never really that passionate about her work. This has been awesome for her because she’s such an advocate. Now, it’s her job to fight with insurance companies. She’s pretty formidable.

Erin Everett: I can imagine.

Sidhbh Gallagher: Yeah. She’s extremely reliable. I trust her endlessly, obviously.

Erin Everett: Yeah. No, that’s great, especially you both have the same vision and want to do advocacy work and make sure that you’re delivering an excellent standard of care.

Sidhbh Gallagher: Yeah, yeah, yeah.

Erin Everett: Yeah. Yeah, because I’m like you. It’s hard for me if I see somebody delivering substandard care. I take it very personally, what I do, and I want to make sure that I’m always delivering excellence with any patient that I see, whether they’re cis or trans or whatever. It’s just a standard and it’s hard for me when other people aren’t meeting that standard. I get defensive just like you.

Sidhbh Gallagher: Yeah, yeah, yeah. Exactly.

Erin Everett: Yeah, that’s great. What’s one thing that you want your listeners to know about you as far as how they can reach out to you and what they can expect from their experience with your practice and your staff?

Sidhbh Gallagher: Yeah. I would say I’ve had two main goals since I’ve gotten in this field because I think education is such a huge part of the whole thing for patients and, obviously, the community as well or the community at large. It’s whole ‘nother story. One of the things I spend a lot of my time and effort in will be social media content. It’s funny I come from an academic background. 10 years ago, I put all my effort into putting peer-reviewed papers together, trying to make information as complex as possible and then these things would sit on the shelf. Now, I spend all my time trying to make comprehensible 15-second videos, but these are watched by hundreds of thousands of people. Hopefully, the community find it useful. I get a lot of positive feedback on that. I would say follow me on social media. I’ve got TikTok. I’m the gender surgeon on TikTok.

Erin Everett: Yeah. Oh, I’ve seen your TikToks. They’re great.

Sidhbh Gallagher: Yeah, yeah. I was a little bit late to the TikTok game. That was my sister’s idea and I really didn’t want to do it. I’m like, “I’m not dancing, I’m not doing that,” but then it’s turned out … because it’s such a challenge because of these complex concepts in there. I have to put them in 15-second videos so I got a lot of fun out of it.

Erin Everett: That’s great.

Sidhbh Gallagher: Instagram, drsidhbhgallagher, then I’ve got YouTube, as well as Facebook, all under my names. Then the only thing I’ll mention just real quick is my pandemic project which was very strange as a surgeon, I couldn’t operate for two months. Myself and all my other friend surgeons had never taken that much downtime. Some of us had midlife crisis or whatever, but a bunch of us got together. I had been working on a book that would basically have very accessible content that was very understandable, lots of diagrams. I had been working on it for two years and I saw this amazing opportunity when all my fellow surgeons were doing nothing to reach out to some really good ones to help provide content and fill out because, obviously, I don’t do all gender affirmation procedures, so they were able to fill it out for me.

Sidhbh Gallagher: We have a book that’s in the process of being published. I’m hoping within a week, or sorry, a month or two, it will be available on Amazon. It’s called Affirmed. It’s just our efforts to try and provide the most accessible, easy to understand, pretty comprehensive, we got pretty much everything from fertility preservation, voice feminization, facial feminization, facial masculinization, all the different procedures covered in there, as well as hormones, mental health. It’s pretty comprehensive. We try to make it as inclusive as possible. The first edition should be coming out in a month or two, and I’ll put it all over social media once it comes out.

Erin Everett: Yeah, that sounds amazing. Definitely let me know so I can pre-order a copy and talk to my patients about it, for sure. That sounds awesome. I think as far as getting involved in your TikToks and things like that, and you talked about changing these evidence-based literature articles down to a 15-second clip, I think that the difference that it makes there for your patients and other … Even if they don’t end up being your patient but people accessing the information you’re putting out there is it makes you more approachable, it makes you real but, like you said, it also delivers information in a way that they’re going to be able to understand it because not that many people, if they haven’t gone through a higher education where they’re reading these literature articles and reading complex medical terminology, are going to understand all that other stuff. Really, you’re just making it much easier for people to feel the courage to get care.

Sidhbh Gallagher: Right, right. Yeah. It makes such a difference. I’m sure you’ve experienced this as well, is what really gives me the chills in a good way is when I’ll read comments from kids who are, let’s say, in rural Mississippi somewhere and they’re trying to come out and their parent is just not understanding it. But when they show their parents somebody in a white coat, so now we have the medical profession, a medical professional is endorsing transgender and non-binary identities, it can actually be very powerful in helping that parent to understand.

Erin Everett: Yeah, I agree.

Sidhbh Gallagher: That sort of thing really, I’m like, “Okay, I’ll make more TikToks.”

Erin Everett: Yeah, right. What also always trips me up when I get an email from someone in another area of the country who’s like, “Oh, my God, I’ve been listening to your podcast and I love it.” I’m like, “Oh, wow, I can’t believe in reaching that many people,” to your point.

Sidhbh Gallagher: It’s humbling, yeah.

Erin Everett: Yeah, it is.

Sidhbh Gallagher: Yeah, absolutely.

Erin Everett: It’s like, “Oh, little ol’ me? What?”

Sidhbh Gallagher: Yeah.

Erin Everett: Yeah. That’s excellent. I’m so excited that we were able to have you on the show and learn more about you. You’re definitely going to be a wonderful resource for my patients because Atlanta and Miami, if you drive, it’s only 10-and-a-half hours so you’re very accessible to all the patients I take care of here.

Sidhbh Gallagher: Yeah. Awesome. Good. Hopefully, they’ll have a great experience. In my new practice, I used to have a nine-month waitlist for not any particular good reason. But now, we’re a lot more accessible.

Erin Everett: Oh, good.

Sidhbh Gallagher: Typically, when a patient reaches out, they should hear back within a couple of days. They should get a consult within a couple of weeks.

Erin Everett: Awesome.

Sidhbh Gallagher: Then depending on the surgery, we can usually get them in weeks to months later, just depending on the complexity of it.

Erin Everett: Yeah. I think most patients expect to wait a little bit and I think that’s fine. That’s the one question I should ask you. Are you doing only in-person consults or do you do virtual medicine for patients a little bit further away who want to meet you first and talk before traveling?

Sidhbh Gallagher: Yeah, virtual.

Erin Everett: Okay.

Sidhbh Gallagher: Yeah, yeah. 90% of our patients fly in. That’s really the design of our practice down here just to accommodate that as much as possible to make it as convenient as possible. Yeah, virtual is definitely for 100% patients. Now with the pandemic, that’s going to be our first stop.

Erin Everett: Right, right. Excellent. Cool. Thank you so much for your time. I really appreciate you.

Sidhbh Gallagher: Awesome.

Erin Everett: Yeah.

Sidhbh Gallagher: Yeah, yeah. Thank you. Very good chat.

Erin Everett: Yeah. Right, right. Exactly. Remember, everybody, stay fierce and live your truth.