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Episode 26 Transcript

FtM Phalloplasty Surgery with Dr. Ellie Zara Ley & Dr. Nick Esmonde

Erin Everett:
Hey, everybody. Welcome back to Exclusively Inclusive. I’m your host, Erin Everett, nurse practitioner. On today’s episode I’m going to be talking to two different surgeons from the Meltzer Clinic, Dr. Zara Ley and Dr. Nick Esmonde.

Erin Everett:
Dr. Zara Ley is an accomplished, board-certified plastic surgeon. She’s extremely intelligent and creative and has an impressive surgical training background with multiple plastic surgery subspecialty fellowships. They allow her to provide superb comprehensive care to the transgender community. Dr. Ley has spent some time teaching at the University of Utah and really enjoyed teaching the full breadth of plastic surgery to the new generation of young surgeons. While she enjoyed teaching, she feels most at home with the Meltzer Clinic, providing surgical services to the transgender community.

Erin Everett:
Dr. Nick Esmonde is newer to the clinic. However, he is not new to transgender medicine or transgender surgeries. He has been spending the last several years at Oregon Health and Science University in Portland, Oregon, where he’s been training and has extensive knowledge in the area. Dr. Esmonde is now full-time at Portland, Oregon and accepting new clients for different types of surgeries.

Erin Everett:
While both surgeons do perform a wide variety of gender-affirming procedures, the topic of today’s podcast is going to be focusing on phalloplasty. We’re going to be talking about how to prepare for surgery, what to expect with the staging, various different possibilities with complications, successes, and the different ways that you can have the surgery done. Both surgeons are very passionate about the trans community and want to make sure that their patients feel heard, and so not everybody has to go through the same process from start to finish. I’m really excited. Everyone take a listen, write your questions down. At the end of the episode we’ll have ways for you to be able to contact the clinic and reach out to the surgeons with any questions you might have. Awesome. Let’s take a listen. Enjoy.

Erin Everett:
All right, I would like to welcome you both to the show. Today we have Dr. Nick Esmonde and Dr. Zara Ley. We’re here to talk more about gender-affirming surgeries. Both surgeons do practice at the Meltzer Clinic, which has two locations, in Portland, Oregon and in Arizona. Welcome to the show.

Nick Esmonde:
Thank you so much.

Zara Ley:
Thanks for having us.

Erin Everett:
Excellent. Nick, why don’t you go ahead and introduce yourself first and let us know what your pronouns are.

Nick Esmonde:
My name is Nick Esmonde, and the pronouns I use are he/him/his.

Erin Everett:
Excellent. What about you, Zara?

Zara Ley:
I’m Zara Ley. I go by she/her/hers for pronouns.

Erin Everett:
Excellent. Thank you both so much for taking the time to be on the show. Really excited. A lot of our listeners have asked me a lot of different questions about gender-affirming surgeries in general. I have previously focused more on vaginoplasties, just because of the way it’s worked out with other guests. However, it’d be really awesome if we could focus today’s show on phalloplasty and anything else that is really pertinent to the masculinizing process. Before we get too far into that, I would like to know a little bit more about you all, as far as what brought you into the field, what your favorite procedures are to do, that type of thing. If you’d like to go first, Zara, that’d be great.

Zara Ley:
My entry into gender surgery was a bit unexpected. As a member of the community, I had looked into gender surgery in textbooks as part of the plastic surgery training, but for me it was also more personal, because I was seeking those same surgeries. I had wondered if it was something that I wanted to do. I thought about going to Thailand to get training done or going to other countries to get it done, because I didn’t think that anyone here in the States would take the time to train me. We’re talking years and years and years back. Now there are more established programs and academic places where they have established programs and so their trainees or residents get exposure to gender surgery, and then they can make that educated decision as to whether they want to incorporate gender surgery into their future practice or like Nick did, take it on full on and say, “This is what I want to do.” That’s how I got into gender surgery.

Zara Ley:
Dr. Meltzer basically saw all my credentials and thought, “You have a perfect surgical background to do this type of surgery. Have you ever considered it?” At that time I just thought, “Yeah, I have,” but I didn’t think he was serious or that he was actually literally asking me to do the surgeries. That’s how I got into it. He basically offered me a job. It didn’t take me very long to say yes.

Erin Everett:
That’s great. Sounds like it was meant to be.

Zara Ley:
Yeah. It took about a year to really get me trained up. He wanted to do the training the right way and not just be like, “Hey, watch me do this a few times and then you’re on your own,” kind of thing, or, “Go somewhere, watch a few surgeries, and then come back.” Now I did travel and I did see other places, just to get an idea of not just how he does it, but how other teams do it. That’s all been very helpful in developing my skills and training. He went about training me up. Dr. Nick will tell you his experience. That was basically the same approach we took with him is make sure that whoever we take on doesn’t just watch a surgery for a couple weeks and all of a sudden become an expert. We wanted a graduated training program where they got exposure, then they started assisting and being more hands-on. I think that’s the right way of going about training surgeons.

Erin Everett:
Absolutely, especially with such personalized surgeries.

Zara Ley:
Right, it’s super specialized surgery. Not every plastic surgery program or other type of specialty program necessarily has that type of exposure.

Erin Everett:
Excellent. Thank you for sharing that. What about you, Nick?

Nick Esmonde:
As Zara mentioned, I’ve been fortunate enough to join their group and learn from two very well established surgeons. I think one of the things that’s struck me along the way is, as Zara mentioned, the more you know about the field, the more you’re really humbled about just how challenging some of the complications can be and how big of a deal the complications can be, not just medically, but socially, emotionally. It’s a very big undertaking so it’s not a training that you would want to rush through. I think that while there’s been this recent kind of preponderance of surgeons performing and offering these things, which I think ultimately will work in a patient training, the training is I would say specialized enough that I really think it was important to get a focused training in addition to what you do as part of a plastic surgery training program.

Nick Esmonde:
At OHSU in Portland, Oregon, I was a junior resident, which means halfway through a six-year program. Around that time, you’re starting to be asked and asked and asked what sort of career you’re interested in. I did spend a lot of time with the craniofacial surgeons, enjoyed facial surgery, facial aesthetic surgery, just for the finesse and the creativity and the powerful impact it can have and reverse time. Ultimately, that didn’t feel quite right. I’d met our new associate program director and new faculty, it was Jens Berli, and he was a surgeon who had came from Hopkins and had pretty extensive training in terms of genital reconstruction, not necessarily all related to gender surgery, but also had taught surgery and had been able to train and travel around the world and come to OHSU and focus on gender surgery. When he showed up and I was able to start seeing the surgeries that he performed and started very quickly seeing the impact it had on the patient’s life, it was almost like a light bulb just went on. I realized that this was the exact field I wanted. I wanted to never look back.

Nick Esmonde:
In the course of my residency, working with a urologist, the ENT sinus surgeons, the of course plastic, was able to travel and present research around the world and just really get as much of an opportunity as I could to learn during residency. Part of it included the Transgender Health Program, which was a coalition of community activists, doctors, and other providers related to the specialty, so I really got to see how surgery was one of a bigger piece of the puzzle and you know I think that while in many fields surgeons sometimes get caught up in the decision making ladder, I appreciated the collaborative and communal treatment planning that went into taking care of patients and how we called on diverse specialties of ? or pelvic floor PT or pediatric endocrinology. I like that kind of work. I like being able to build a coalition, and this is a rambling answer, but especially as adolescent care is taking off and we’re seeing more and more adolescents in surgery, you really realize there’s new issues, new training that needs to come to be able to serve them, because they’ve historically not had access to these procedures. Needless to say, it was a very meaningful and wonderful experience. Then after residency, I was able to join the Meltzer group after we met when we were traveling abroad for research.

Erin Everett:
That’s cool.

Nick Esmonde:
It’s been the most extraordinary experience in my life. Every day just gets more and more interesting.

Erin Everett:
How far into it, in the one-year process of before being the full-time associate surgeon in Portland?

Nick Esmonde:
I’m now full-time in Portland.

Erin Everett:
Oh, great.

Nick Esmonde:
Starting I guess just this past month.

Erin Everett:
Awesome. That’s very exciting. You’re working on continuing to offer … Which surgeries do you mainly focus on, or do you do a little bit of everything?

Nick Esmonde:
I think within our practice, our setup, that we all will offer everything, with the caveat that there are some procedures that will go more towards the seniors in the group, some more complicated revisions, reconstructions on say if somebody had a vaginoplasty and had a complication and needs a secondary procedure. Things like that, we’ll gravitate, but in general we offer the same procedure and then based on complexity or interest, we can pair up or help how things are done.

Erin Everett:
To me that’s completely mind-blowing that you are all so talented to offer such an array of surgeries, because each individual surgery itself is quite complex. I’m impressed and very excited to pick your brains today about it all.

Nick Esmonde:
One thing Dr. Meltzer just mentioned to me, he said in his training, and I’m sure it’s the same with Zara’s, that the culture was that you don’t consult out, subcontract out parts of your surgery or a person’s care. You really gotta understand the whole thing. It’s one of the things I was amazed is that Dr. Ley and Dr. Meltzer really perform the whole gamut of surgery, including managing urologic complications, complications with the head and neck, complications from other centers. It’s very important to be able to offer a full spectrum so when the patient comes to you, they feel like they can be taken care of.

Erin Everett:
I agree. I think it’s very unique to have that kind of comprehensive approach.

Erin Everett:
A few questions that I had, and I guess they could be directed at both of you, is more in detail about the phalloplasty, and some questions that patients often ask me is the staging process. I know a lot of different clinics do it very similarly, but other people have their own unique way of doing things. One of the questions that a listener had was, “How do you all stage phalloplasty? What should a patient expect when coming to your clinic about the whole process from maybe even beginning the consult to how many different types of surgical procedures could they expect or are things done more in one go? If you do split it up, what is the approach to that?”

Zara Ley:
A phalloplasty in general is a bit of a broad topic. There’s different types of phalloplasty. I think for a potential candidate, they have to decide first of all what type of phalloplasty they want to have, whether they want to go through the microsurgical pathway or the pedicled phalloplasty options, which does not require as extensive or as complex of a reconstruction.

Zara Ley:
Another decision that patients have to decide on is what their ultimate goal is, especially when thinking about voiding. Some patients get phalloplasties without urethral reconstruction. They can still have erectile device placed and so that it works in that manner, but they won’t ever be able to void through the actual neophallus, as opposed to someone who wants to, I guess you’d call it go all the way. There’s no right or wrong way of doing it. It’s just what’s right for the patient. For those patients who wish to have a phalloplasty with urethral reconstruction, then there are additional options, perhaps additional stages to address the urethral portion of it so that they could pee through their actual neophallus. That’s the complicated part.

Zara Ley:
The first thing is knowing what you would like or certainly what to ask about those types of procedures, because they all come with their own sense of challenges and potential complications and like I said, perhaps even additional staging for that. That’s the very, very first thing that they need to decide.

Zara Ley:
It also depends on where that tissue comes from. They have to keep that in mind. When I talk about the pedicled options, we’re talking either ALT or groin flap. Phalluses sometimes come from the groin crease. Those types of wounds are closed in a single line and they’re easy to hide, because they’re under the shorts and the boxers and briefs. Unless you’re totally naked, no one is able to see those, whereas the microsurgical option, especially when we’re referring to the forearm, it leaves a substantial scar in the forearm. That’s very, very hard to hide. Now people can wear a sleeve all the time or tattoo it once the wound is healed, but they will always have a rather large and sometimes bit of an unsightly scar on the arm.

Zara Ley:
I see enough patients seeking phalloplasty that they weren’t quite aware about that part. They don’t want it, because they can’t hide that cut. Dr. Meltzer has always commented, it just takes one celebrity or one very famous, open, out trans male to undergo this procedure and show the world what their scars look like, then other people are going to start picking it out. They’re going to see someone’s arm scar and be like, “Oh my gosh, that’s a … ” They’ll be able to be clocked easier.

Erin Everett:
All of a sudden they’re not as stealth.

Zara Ley:
“That person had a phalloplasty,” or, “That’s a transgender person.” Those kinds of things matter to patients. They have to obviously be aware of it. That’s what I have to say as an introduction to phalloplasty is that there isn’t just one type. Like I said, there’s no right or wrong. It just depends what their issues are, what their goals are, and whether they are willing to accept the scars that go along with whichever chosen procedure.

Erin Everett:
That’s super informative, because I’m not even sure that I knew that you could actually have the neophallus without the option for urination and keep your urethra that you were born with. That’s fascinating to me.

Zara Ley:
We can go through a typical scenario of someone who wants a phalloplasty with urethral reconstruction. We could talk about those stages. That is the most complicated one. Everything else is…It’s still complicated. Don’t get me wrong. It’s less steps than that. We can certainly go over that. Maybe Nick could go over just what a typical full-on reconstruction stages involve.

Nick Esmonde:
Sure. That’s great. I think you also hit on something which is important and that I appreciate more and more is that patients coming for phallo, sometimes they come from Victoria or Canada and liberal parts of the West Coast, and this idea of being clocked, it doesn’t even come up. That’s because they’re within a community that’s safe, supportive, accepting. That’s not an issue. Seeing patients from all over Midwestern, Eastern, East Coast United States. That’s a huge factor. It’s a little unsatisfying sometimes when patients want to just know a basic answer like, “How many stages? How do you do this?” There’s just so many asterisks and caveats that it’s hard to give a straight answer until you can really go through a person’s wishlist, preferences, and get a sense for where they’re most risk-adverse, and then you can give them a little bit more concrete information. It continues to surprise me how patients can have a perfect … They can really understand 95% of the whole surgery they walk in the door, but then it’s that little piece about their personal anatomy or whatever makes it hard to know, like: you’ll be done in three steps, in 12 months. People often want to hear something concrete.

Nick Esmonde:
Let’s just take an example of somebody who’s in and their stated goals are to have a urethra, which means a tube through which you pee, to be able to stand to pee, to be able to have tactile sensation, meaning detecting whether something’s being felt on the penis, and even erogenous sensation, and then let’s say they also want to go all the way up and finish with a erectile device and testicular implants. That’s a full package. Again, not saying that’s the gold standard. That’s just the most that somebody might pursue.

Erin Everett:
In general.

Nick Esmonde:
Starting from scratch when they come in, we assess their donor sites. There’s two main donor sites in 2021 for giving somebody a tactile phallus that has sensation. It’s either coming from the leg, which most patients aren’t a candidate for, because the tissue is just too thick or the forearm. That’s what’s called the radial forearm free flap. That’s considered for most groups I would say around the country the gold standard in terms of being able to get the right shape, reliable blood supply, the most predictable outcomes with surgery in terms of when you transfer tissue and its vulnerability, the most predictable course of healing, and least anatomic variation, among other things. A radial forearm would be, if you asked the surgeon what would be the best one to do, it would be that, and I think for most patients, knowing what you can most reliably give them.

Nick Esmonde:
Their first stage, after undergoing electrolysis for approximately a four-centimeter longitudinally along the forearm to get rid of hair in the area that’ll make the urethra. The flap is a large rectangle tissue that’s rolled. The first tube is the urethra where you pee through and the second tube is the outside skin. The outside skin can have hair on it, no problem. You could treat it later if you didn’t want it, or you can just leave it alone. The inside skin, if the patients have dense hair, and of course with testosterone a lot of patients have dense hair, we require electrolysis.

Nick Esmonde:
I saw a note in your email ahead of time about pain control for this. Actually Dr. Meltzer and I were just talking about offering just wide local field injections, so injecting a bunch of numbing up and down the arm, as we do for numbing the scrotum before electrolysis for vaginoplasty. We’re going to start offering that too. I don’t know, Zara, have you done that? Dr. Meltzer said he hadn’t done it, but he said he’d start offering it if people wanted it.

Zara Ley:
I had not done it for preparation for either urethral microsurgical reconstruction or full phalloplasty reconstruction, but it really wouldn’t be any different than offering it, like you said, for scrotal electrolysis for the women. We are able to use longer-lasting local anesthetic. As long as their local anesthetic injection and their electrolysis appointment relatively close by, they ought to be able to go through a full session of electrolysis through the entire required area with just that dosage of local anesthetic.

Erin Everett:
That’s awesome.

Nick Esmonde:
That’s I think one of the things hopefully patients can come away with from this is understanding where some of the hard stops are. Electrolysis is a hard stop, meaning if somebody has dense forearm hair, one of the things that’s going to prevent surgery from happening at your scheduled date would be if electrolysis doesn’t get complete. I think sometimes people leave the office with a dizzying amount of information and they have to get letters from mental health. I try to give people the impression like, “Hey, job number one is get on the books with an electrologist so you can get your electrolysis started.

Erin Everett:
I think that’s not a roadblock, but that’s a challenge, because I don’t know about other areas, but here in Atlanta there are just a few really good ones, but a lot of them have a one-year wait list.

Nick Esmonde:
Exactly.

Erin Everett:
I’m trying to collaborate with some to offer that local anesthetic so that they can then go over to the electrologist and have a much longer session and get much more accomplished. That’s part of it, because their electrologists are like, “I don’t know what to do. These people show up and they’re like, ‘I have surgery in six months,’ or whatever, but I can’t even see them for several months. Then when we do have our sessions, they can’t tolerate it beyond an hour or something.” That’s something that we’re trying to work on here locally to open up so that we can make that process a lot more efficient for the patients.

Nick Esmonde:
I think we could do a whole separate podcast honestly on that.

Erin Everett:
For sure.

Nick Esmonde:
I gave a talk on it for the WPATH meeting, but I think it’s such a no brainer once people realize you can really decrease the frequency of these electrologist sessions for patients and make it more comfortable and cheaper. It takes the resources and there’s probably only a few people that do it right now. It’s not any specialist training.

Nick Esmonde:
Getting back to the staging, not to leave you hanging, so if somebody is able to get electrolysis and get everything in line for surgery, we stage the creation of the penis, the phallus, with the urethra inside. Again, that’s a tube within a tube. Then we do microsurgery, meaning transfer the tissue and hook it up to a blood supply just using a microscope, and then it sits in the anatomic position just in front of the pubic bone. That’s really most of what the first stage is. The first stage, the process of transferring tissue is rife with potential complications. I think both Zara and I have a lot of training in microsurgery. These surgeries of course we feel comfortable offering it, but it’s not without risk. Ideally we like to see the tissue transferred and see the patient has healed entirely from that. At this point we have not touched any part of their urinary, have not created any urethra. Their urethral plumbing, as it were, is all intact. If, god forbid, anything fell apart and there were issues with a phallus that didn’t work, all their natural anatomy would still be in place, which is important, so you’re not leaving fissures and strictures and rerouted urinary stream.

Nick Esmonde:
There’s a substage in there where we just put a skin graft on the arm and then let them heal from that. Then three to five months later we do what’s called urethral lengthening. It’s connecting their native urethra, it’s about 8 to 10 centimeters, up to the urethra of the phallus, connecting those, creating a scrotum, creating a glans, which is the corona shaped tip of the penis, and then giving him a urinary diversion via suprapubic tube. At this point all of the plumbing is hooked up. We allow it to heal. The outside of the penis is shaped. It really takes on, at this point, a pretty satisfying look. As you create the glans, it really gives it the sense that now it’s here. It goes from a plain cylinder to a more familiar shape. Then they’re allowed to heal. At this point it becomes a decision of whether they want testicular implants ultimately, which of course we use the solid silicone in the testicles, sometimes during tissue expansion before that.

Nick Esmonde:
Once they get sensation in their penis, and you want to have sensation, because you want to protect the sensation, meaning if you’re going to put in an erectile device, something that’s going to be stretching and pulling and tugging on the skin, you want to have sensation that could tell you ouch or that hurts or something’s wrong, don’t do that. That would be the last stage, a year later.

Erin Everett:
Does that have anything to do, that sensation, with sexual pleasure as well?

Nick Esmonde:
It can. Of course you’re asking somebody who hasn’t had it themselves. It’s an amalgam of the different reports I’ve heard or read. I think patients report … so basically it seems like patients report something between familiar sensation, pleasurable sensation, and then if, through the combination of sensation of the penis and the location of the clitoris, which is preserved, but buried beneath the penis, so it can still provide some stimulation. Happily to say, a very large amount of patients are able to orgasm, if that’s through some combination. Now exactly how that works, what’s contributing what sensation, it’s hard to say.

Erin Everett:
Cool.

Zara Ley:
One thing to mention is that the sensation of the nerves that we connect takes a long time to regenerate. We’re talking about a year. The earliest any one of our patients reported being orgasmic through their new penis was nine months. Most patients are past a year. Unfortunately, it’s not everybody either. It’s something that we can’t guarantee, that they can be orgasmic. Like Nick said, it really is multifactorial. A lot of things come in to play to orgasm. It’s no different in our trans women after vaginoplasty. It’s not a guarantee, but it is a potential benefit of surgery.

Erin Everett:
Would you say the majority will end up with that outcome?

Zara Ley:
I would say half, for sure, to be completely honest.

Erin Everett:
That’s good. I think it’s really important that people have a realistic expectation.

Nick Esmonde:
That sounds right. It’s the things that portend better outcomes in general when you’re reconstructing nerves, younger patients across the board, if you look at just who recovers nerve function after nerve repairs, which is essentially what we’re doing, a nerve repair, younger patients do better. If you have to graft, if you don’t have to use extra nerve to make the connection, it’s basically a race between how fast the nerve regrows and how much the tissue that it’s regrowing into is willing to wait for it. Again, depending on a few caveats, we use two nerves that can go to the phallus. One is a nerve borrowed from the clitoris. The clitoris has two paired nerves that are offer sensations in clitoris. One of those nerves is transferred up to the phallus. Then if an applicable nerve from the upper inner thigh can be transferred there. You can get dual innervation, sort of, sensation of having the clitoris below the phallus. I would say that part is still currently being studied and is certainly of interest to a lot of patients. I think at the end of the day most patients, at least the ones I’ve worked with, prioritize having their urinary function as the highest, before and after.

Nick Esmonde:
Can I say one thing that just come up recently in our clinic? I’ll try to keep it really brief.

Erin Everett:
Yeah.

Nick Esmonde:
I think a hot topic, or at least a controversial topic, is weight cutoffs for surgery, not just wait times. Let’s say a patient finally somehow gets everything together, they got the insurance, they’ve been jumping through hoops for months, and they finally get an appointment with the surgeon and they call the office and they say, “Because of your weight and height, you can’t do the consult. We don’t do anybody over X or over Y.” Then that’s it. It’s terrible. You hear about that. I think that there’s a consensus that weight matters, but people don’t necessarily know how to quantify it, how to describe exactly why it matters. How weight is distributed in everybody is different. I think it’s important to know that weight matters only inasmuch as it will make your surgery potentially less successful or less healthy.

Erin Everett:
Maybe delayed healing times?

Nick Esmonde:
Yeah. I encourage patients that get turned down based on weights to at least reach out and talk about it. I think one of the things I’ve identified is I’m going to start referring some of our patients to our hospitals. They have a supervised nutritionist program that takes in patients that can follow them month by month, rather than say, “Lose 50 pounds and come back,” which I think most people having sort of grown up hearing it, you can give them a more tangible resource. I don’t know what ultimately is going to be the most effective resource, but I think it’s important to know that weight is itself … I wouldn’t say we have a certain cutoff, but if I see somebody, or any of us see, who have weight above and beyond what I think makes it safe or feasible to do the surgery, that we’ll try to explain why and go through strategies or talk about alternatives.

Erin Everett:
Yeah, because I can’t imagine being told, “Lose 50 pounds and come back,” is overly motivating for most people, and often probably extremely difficult to do, because as if people haven’t been struggling with their weight their whole lives anyways.

Zara Ley:
There are other options too. Has to do with weight distribution. We don’t look at a singular number like BMI. BMI is just a number. Yes, it matters, but it also matters where the fat distribution is. Sometimes a patient can benefit from say a mons resection or even a panniculectomy, and maybe that’s all they need to get them to be surgery-ready, if that makes sense. What that does is just facilitates that area for the surgery to be done. You can’t attach a phallus to the mons when it’s four inches thick.

Erin Everett:
Makes it more challenging.

Zara Ley:
It’s much more challenging and maybe even a bit impossible to expect that to do well after surgery, especially with a pannis that would otherwise be laying on top of your new penis. We have offered that to patients and gotten them through surgery successfully by offering these options. Of course that doesn’t apply for everybody. The point is that we do do our best to try to obviously not discourage the patients, like Nick said, give them alternatives, give them as much help as they can to try to lose the weight, but also see if there are other things that can be done to perhaps facilitate that process for them.

Erin Everett:
I think that’s great. I’ve had several patients reach out to me before to establish care for the continuation of hormones and also just discuss weight loss options, because they had been turned down by multiple gender surgeons because of their BMI. Again, when you meet the person in person, depending on the surgery that they’re seeking, it’s like, “I don’t understand how this could even be an issue. That’s not even where you carry your weight.” As long as their chronic medical issues, if they even exist, are under control, then I’ve been able to reach out and find other surgeons like what yourselves are saying, who don’t just look at that BMI number and will actually meet the patient and consult and look at that actual anatomy and see what they need to do to either customize or change the approach in which they do the procedure.

Erin Everett:
I think that’s really good, because one of the things that I try to preach to patients is you can be healthy at every size. I think a lot of people in general have had disordered eating, have been denied good, safe health care based on their size, and so I think that’s really unfortunate when people, like what Nick said, get turned away just because they see a number and they’re like, “Lose 50 pounds and come back.” I don’t know how you expect them to do that when they’ve probably been trying to lose weight their entire lives and have been unsuccessful. I think that’s awesome that you guys are navigating that and offering them good, solid resources to help them achieve their goals.

Nick Esmonde:
I think it remains to be seen what’s the most effective way to help people get there. I think the other thing would be an honest conversation about look at plan B and C and say, “Let’s say we don’t get there. Here’s what’s still on the table.” I think being able to have that … The last thing I want is somebody to leave feeling hopeless. I want them to feel like there’s the plan and there’s a backup plan. If there’s one thing that’s great about plastic surgery, it’s that we can always come up with some other new option or tweak, and it’s a field that’s founded on adaptability and creative thinking when it comes to how someone’s reconstruction’s done. If it just doesn’t come together for somebody, making sure they still feel like we can give them some options to take home.

Erin Everett:
For sure.

Erin Everett:
One of the other things I wanted to ask, since we were talking about potential complications and long-term considerations was, someone specifically asked, we already touched on the importance of hair removal prior to the surgery, but if someone did undergo electrolysis but for some reason it wasn’t completed adequately or they did experience internal hair growth, what are the implications of that, internal hair growth inside the urethra?

Zara Ley:
What happens is that hair serves as a filter through the new urethra. The urethra is obviously buried within a penis. Access to those hair follicles is extremely difficult. The urine is obviously full of waste. That’s why we all urinate. It has minerals. It has electrolytes in there. It has all kinds of stuff that eventually as it basically filters through this hair sieve, it forms calcifications. You can think of it as hard water going through faucets and that calcium buildup forms around the mouth of the spout. That’s what happens to urethras that have a lot of hair in it. Then it becomes an obstructive complication. You can’t pee because your pipe is clogged up basically. There are ways to treat it, but they are not necessarily the most effective or the most easy. I know that you can put in a laser light up in there and try to zap it. You can chemically try to treat it, but you have to balance that with potential damage and/or scarring to your new urethra, which then can lead to scarring issues.

Erin Everett:
Strictures I imagine.

Zara Ley:
Exactly. Strictures and things like that. That’s really the implication of not having thoroughly done the hair electrolysis. Like we mentioned earlier, it’s a bit of a hard stop on proceeding with some of these urethral reconstruction is the hair.

Erin Everett:
I’m guessing then that if someone does believe that they’ve had complete electrolysis of the area, that’s not a common occurrence for you to see that type of thing.

Nick Esmonde:
You mean if somebody has had electrolysis and to go on to develop hair in the urethra anyway?

Erin Everett:
Yeah. If presumably they’ve had-

Nick Esmonde:
No. What we’re talking about is more thick, dense hair that’s right there when you’re starting the surgery.

Erin Everett:
It’s not likely for a patient to believe that they’ve undergone complete electrolysis and have that occur later?

Nick Esmonde:
Electrology is a little bit of a … It’s a delayed effect that you see over time. Electrologists can’t say on any given day you’re ready or you’re done or whatever. What they’re assessing is the growth of these hair follicles in three-month cycles. If anybody is out there wondering, “Why is it taking forever? Just go in and zap it and get it over with. I’ll stay as long as I have to,” you can zap all the hair you want, but then what the electrologist wants to see is what hair returns, how much, and what pattern, what density, and so on and so forth, after it goes through this two or three-month growth. As to being able to really say, “Yeah, I think we got it all,” it usually takes seeing it over a couple different growth cycles.

Erin Everett:
To ensure.

Nick Esmonde:
Yeah. It’s not a step that you want to skip over. You wouldn’t want to just get electrolysis … electrolysis just before the phalloplasty. It’s why it is one of those things you want to get started early. Then of course if anybody’s out there trying to say, “Okay, I’ll start, I’ll start, just tell me what to do,” I think it’s important for, if your electrologist is not familiar with the pattern of hair removal, to get in contact with the surgeon’s office early, rather than have somebody try to guess and say, “I think somebody from so-and-so from Belgium used to do it this way, so I’ll just take the hair here.” It should be incumbent upon the surgeon providing information apparent for the patient and the electrologist about where hair removal should be. I’ve seen instances where people got the wrong area or incomplete. Probably just check in and try to I guess …

Erin Everett:
Yeah. I think that’s important to note too, because I have spoken to a local electrologist here who mentioned sometimes it’s hard, because patients, if they haven’t gotten that information from their surgeon, he’s like, “Okay, so what area am I working with then? I need to know exactly the borders of where they’re going to take the graft. I think, like you said, a good educated electrologist, not just someone who’s doing it for other cosmetic reasons, one that’s actually doing it in preparation for people undergoing affirming surgeries is really important.

Zara Ley:
One thing that I have done for patients is I have literally measured out and marked their arms.

Erin Everett:
That’s awesome.

Zara Ley:
In consultation. And they can take a picture of it and they basically take that to their local electrologist and be like, “Okay, this is the exact area that needs to be done.” I think that’s about as customized as you can get.

Erin Everett:
I think that’s perfect.

Zara Ley:
On the other hand, there are patients who are relatively hairless, especially over certain parts of the forearm. Usually the inner part of the forearm tends to be less hairy. It’s not everybody. Some people are super hairy all the way around. I have had patients come in for phalloplasty that actually do not need electrolysis because the area of where the urethra portion of the reconstruction would come from has no hair whatsoever, naturally. It’s really the urethral portion of the forearm that needs the electrolysis. A common question is, “Do I need the entire arm done?” The answer is not necessarily. You definitely have to get the urethral portion done, but the rest of it, you can do it afterwards for electrolysis. What that means is that the hair’s going to end up on your penis, on the outside. But because it takes so long for the sensation to come back-

Erin Everett:
You wouldn’t even feel it.

Zara Ley:
… you can actually get all of the electrolysis. Exactly. You can get all of it, external, penis shaft, head, electrolysis done with no pain whatsoever.

Erin Everett:
I didn’t even think about that.

Zara Ley:
Without harm to the penis. Without harm to the new penis. It’s tough. Of course you have to wait for everything to heal before you start stabbing needles into it. Those are some of the variations that we do see. Not everybody needs it done. The common question, like I said, is, “Do I need to do the whole thing?” The answer is no.

Erin Everett:
That’s perfect. One other question too I wanted to make sure I asked about was what to expect and what the rates are of people who might have chronic pain or discomfort with urination. Is that something that you guys see? If yes, is it common, not common? What ways can you manage it?

Zara Ley:
In terms of chronic pain or any kind of pain, in terms of urination, I don’t hear that very much.

Erin Everett:
That’s good.

Zara Ley:
I do hear more commonly about urination is dribbling. That’s one of those things that once you’re fully reconstructed, whether that’s primary urethral lengthening or metoidioplasty only or primary urethral lengthening and full phalloplasty with urethral reconstruction, is the dribbling. What happens is that the new urethra, the extension of the urethra, and the phallus urethra doesn’t really have any contractile properties like a natural urethra would have. Squeezing out that last bit of urine can be an issue. What happens is that the urine collects in the new urethral segment. Guys learn to milk their penises and their urethras to get all of it out, because I’m sure it’s mortifying and very embarrassing to finish peeing, you put it back in your pants, and all of a sudden you have a wet spot on your khakis.

Erin Everett:
That would not be ideal.

Zara Ley:
If anything, that’s what I do hear about. That’s when we try to teach the patients, okay, you might have to stand there a little bit longer, milk it all the way from the bottom out to the tip kind of thing. I can’t think of an occasion where someone’s like, “It hurts to pee,” all the time.

Erin Everett:
I recently had a patient who underwent surgery and had a question about that because they do have a pain every time they initiate urination. They’re pretty closely post-op and we’re trying to manage it. They wondered if that was something that was common.

Zara Ley:
I don’t know that patient’s particular situation. If they have a stricture, maybe it’s just it’s harder to push that initial urine volume out through the narrowed part and so it backs up and maybe doesn’t…? I couldn’t say without really knowing the patient.

Erin Everett:
For sure. It sounds like in general with the way that you stage out the surgeries and prepare people for it, you don’t typically see a lot of post-op complications and people tend to have long-term satisfaction with their surgery. Would you say that’s accurate?

Zara Ley:
For centers that do a lot of phalloplasties, especially microsurgical phalloplasties, some people will literally say microsurgical phalloplasty has a 100% complication rate. That’s an exaggeration, but when you think about wound issues, any little thing obviously could be considered a complication. I think the complication rate, I wouldn’t say that it’s low, but it’s not necessarily catastrophic. Total loss of the penis is extremely, extremely rare at any major, experienced center. Things like stricture, fistula, I’d say those are bound to be common but fixable. I wouldn’t really want to give someone an impression that it’s relatively complication-free. I don’t know. What do you think, Nick? I wouldn’t want someone to come out with that impression. Certainly complications do happen. It’s one of those procedures where the complication rate I think tends to run higher, but most of these things are fixable.

Nick Esmonde:
I think what’s important for patients to know is of course the risks at each stage. I think for the groups, that now include ours, that stage it in this way, try to break up an overall very risky endeavor in terms of getting it to all work correctly. You try to break it up into the subset procedures that with each one of them you could wrap your hands around and get a hold of the complication, whatever it might be, big or small, and get it dealt with so that you can get to the next stage and gear up for that. The worst thing would be if you had some complication that then spilled over into the next component of the reconstruction. Say part of the penis dies, but in the process of doing that, you lose the connection to the urethra, so the urinary stream has to be rerouted or they have to be diverted or these things can domino quickly. I think if you take a little more measured approach, you can say, “Let’s just take on and accept all the risk and potential for complications with each stage,” and make sure it’s all done before you go to the next one.

Nick Esmonde:
I think what I learned during residency, I think it’s really helpful, because the stages, the clock’s not ticking. Once you’ve done one stage, you can wait 10 years to go to the next one, whatever. Let’s get you through this stage and I’ll tell you what may or may not go wrong and what the challenges will be. Let’s get you through it, and then when you’re ready for the next one, let us know. Some patients turn around and sign up for the next stage right away. Other ones wanted to say, “I need a year or two.” I think as opposed to just stacking up all the potential for things to go wrong, I think everybody knows that phalloplasty has a high complication profile in terms of getting urinary tract to work and all that, which is great, just don’t come in expecting like they buy a brand new car off the lot. They know it’s a serious undertaking. Our job has been to make it as safe as possible and as manageable as possible if and when there’s some issue. I think patients respond to that well, because … yeah.

Erin Everett:
I think anytime you set up the expectations clearly, patients do better with that. There’s no surprises, per se. If they know it’s, “This is possible. This is possible. You might not experience any of this, but you might experience all of this. We’re going to do our best to reduce that possibility,” I think then when you set the expectation and the tone, they roll with the punches a lot better.

Nick Esmonde:
I think another thing that’s important for listeners to take away, especially since this is a national audience, or whether it’s, if you end up having us perform you’re surgery, just looking, figuring out very early what the travel and away from home time is going to be and just realizing that as you’re making plans. I think in Arizona, we usually have somebody stay there between four and six weeks to get the first little group of procedures done, make sure they’re recovering and be able to send them home feeling pretty confident that they could go back to state X, and they could manage most of the stuff remotely if something came up. In Portland I think that my sense is already, just from what we’ve been seeing in clinic, there’ll be more patients living closer. So I think patients stay for 2-3 weeks, which means I think that they have the potential to go home a little bit earlier, because they could come back easier, which is just not the case if somebody lives in New England and has to fly back and forth to Scottsdale to manage something sooner. Then they stay just longer in Arizona and do other things. Hunky dory.

Erin Everett:
I could see that, because Portland, Oregon in general is a lot more inclusive than a lot of the places that these patients travel from. That’s excellent.

Erin Everett:
Hey, everyone. I have a quick favor to ask. If you wouldn’t mind taking a moment and just clicking the subscribe button on whichever platform you use to listen to my show, that would be wonderful. Not only does it allow you to get notified every time I publish an episode, but it also helps with my ratings and reviews, which what that means in podcast world is that I’m able to climb up on the rating scale and reach other listeners. The whole reason why I started this show is to access people who needed the information. Please just go ahead and click subscribe. Then we can all be happy and continue to listen to this good quality free information. Thank you so much.

Erin Everett:
The only other thing that I wanted to ask is as far as when a patient is wanting to establish with the Meltzer Clinic, is it really just up to them which location they want to be seen at, or what’s the process if they were to reach out to try and get a surgical consult?

Zara Ley:
It’s up to the patients which location. I notice that patients will pick not necessarily in terms of location, but more as in timing. Which location can I get in faster or for whatever timing, time frame that they have in mind. That’s one thing. Otherwise the location I don’t think really matters to some folks. Obviously, those who live in the Northwest would probably really just prefer to stay in the Northwest, just because travel is less of a nuisance. Others just want to get away from the weather and be like, “It’s beautiful in Scottsdale.” Not in the summer.

Erin Everett:
I was just going to say, everyone’s probably really hot right now.

Zara Ley:
People are willing to travel. Most of our patients do come from out of state, all over the country. It’s not hard to pick Oregon over Arizona if you come from really far away. They would just have to call and figure out what the timing is, which surgeon they want to go with, there’s three of us, we all do the same thing, and go from there.

Erin Everett:
Excellent. Very good. Before I let you all go, is there anything else that you want to make sure we chat about today or anything you want the listeners to know?

Zara Ley:
I was going to say a little bit about the complications in the phalloplasty, just so it doesn’t sound so grim, like your going to take on this, you’re going to almost die before you come out the other end. It’s not [inaudible 01:00:28]. Patients do come through relatively unscathed. We do have the success stories where it’s like, “Wow, you really made it through all these steps pretty darn well.” Patients do get through. That’s the only thing. Yes, it sounds like there are a lot of complications, things like that, but it’s not 100%, as I exaggerated. People do get through and they do well. Because it’s not always like that.

Erin Everett:
It sounds like some of the complications that patients can experience might be more of little bumps in the road or hiccups, rather than, like you said, anything major or that would really put a stop on their progress.

Zara Ley:
Even if something major does happen, Nick alluded to this, we’re plastic surgeons, we’re pretty creative. There are options and there are ways to get around it. I’ve been able to face some major complications and still get them out the other end just as well, just a bumpier road and a longer time frame.

Erin Everett:
Excellent. Awesome. Nick, is there anything you wanted to add too?

Nick Esmonde:
I think it’s good for folks to know that we’ve been doing these telehealth appointments and been staying busy. I think it was partly due to rules that changed during COVID with which states have interchangeability with our medical licenses and things like that. I think getting telehealth consult is a new option. Even my PCP office offers it. I’m like, some people are like, “What? No. I want them to go in there and listen to my heart and lungs or something.” You realize most of what you’re getting is a conversation and someone to help you go through complex information and weigh the risks and benefits. Of course a physical exam is essential for surgery. It doesn’t really obviate the need for that, but at least gets the conversation going.

Nick Esmonde:
I think the number of misconceptions or partial misconceptions or even things where people are like, “Oh, I read on Reddit that your group only does this little maneuver.” Some little surgical step that I wouldn’t expect anyone in the world to know, it’s got a Reddit sub-thread on there. You’re like, “What? Where is that from?” It’s not malicious. You spend time unwinding that, “Hold on. First of all, everybody does that,” or whatever it is.

Nick Esmonde:
Getting information, and especially with phalloplasty, I’ve not seen a diagrammatic or pictorial way to represent the steps other than just some comic meme where somebody’s got a million bullet points on the wall and all the strings connected. There’s a lot of ways to get to the goal. You can take a lot of routes. There’s a lot of caveats. It’s a little frustrating sometimes to not be able to give patients a clear information, like one’s two steps, whatever the whole thing is. There’s just a lot. There’s a lot to it. Getting people to get in contact early I think is important. I think the telehealth is a great way to do that.

Nick Esmonde:
Then just in general our patients show up with more asterisks of these complications, so that we’re not, you know, when you talk complications it sounds doom and gloom, but it’s more that there are setbacks, that for the most part, most of these complications don’t stop the process and they’re done. It’s more like setback, have to delay, do an extra step, divert the urine. Complications is a catchall term in surgery to say, “Darn it, I wish it had gone better,” or something like that. It doesn’t necessarily mean that like, we’re done.

Nick Esmonde:
I think one of the nice things about being a gender surgeon as your primary gig is that when you offer these surgeries and when you do it, you understand the context of what patients do to prepare for surgery, what it means when it doesn’t go right, and what it means to have a longitudinal relationship with them. I think we’ve been humbled by how just even in year five or six of doing this between residency and training, I’m still humbled by how little I really know, or how much more there is to know about how to really take care of patients beyond just the surgical piece. I find myself now like, it’s back to the books, let’s get some more courses on, like I said, adolescent hormones, or whatever, other things to be prepared for, you know, you want someone that’s confident that they’ll see through it to the end.

Erin Everett:
I agree. There’s always more to learn. Sometimes people even ask me, I just do medical management, but ask me questions about things like long-term health risks and all those types of things and, “Why do I do one medication over another?” I’m like, “There is no study on it. I’ve just got hundreds of patients and I just know what works.” Sometimes it’s just gaining experience and knowing what people need and trying to adapt it and not doing what I call, quote, cookie cutter medicine. I think that’s great that you all have a similar approach. It sounds like when a patient arrives at the clinics that they get a very individualized assessment and, like you said, you’re addressing their personal goals and needs as well.

Erin Everett:
I just want to thank you guys so much for taking the time to chat today. I’m really excited about this. I know that my listeners are going to be excited about this information. If they have any followup questions or they want to reach out to your clinic, which is the best way for them to do that?

Zara Ley:
Through our website, I would think. It’s got our phone number. It’s got all our contact information. Someone can just Google the Meltzer Clinic and the information for the office is there, email, locations, stuff about us, the surgeons, and they can make a decision on what they want to do, who they want to go with. Like I said, we all do the same thing. We were all trained ultimately by Dr. Meltzer, who was back in the day the do-it-all person, because he was one of the few.

Erin Everett:
One of the trailblazers.

Zara Ley:
I know we’ve mentioned this before, is that one thing that is very special about our practice is that we are truly a very comprehensive gender surgery center where we literally do it all.

Erin Everett:
You guys even offer hormone therapy too, right?

Zara Ley:
Yeah. We offer hormone therapy. I think that our experience, just because, I can’t take credit for it, Dr. Meltzer, again, is one of the giants in gender surgery. Due to his reputation and his experience, I was able to build a solid practice based on that, and not just that, but just the amount of exposure, the amount of patients. I’ve only been in this for six years, but compared to other folks six years out, I just so have so many more patients.

Erin Everett:
Your experience is far more comprehensive.

Zara Ley:
Right, because Dr. Meltzer really, and Nick’s going to have the same thing, based off of Dr. Meltzer, based off of me, and then he’s going to build a giant practice and hopefully we take on more people as we get older and put out more conscientious, good, caring gender surgeons out there.

Erin Everett:
Awesome. Nick, does your location offer hormones as well?

Nick Esmonde:
Not explicitly through the clinic, but I think the way a lot of the hormones are managed … I’ll back up. The person who manages hormones, at the Arizona clinic, I don’t think she could do across state lines. That might be possible. I don’t know.

Zara Ley:
I don’t think so. She would need a license in Oregon. She’s a nurse practitioner and she’s involved in WPATH. She does keep up with the HRT literature and treatments.

Nick Esmonde:
In that case it would be the hospital Legacy Good Sam. has a Gender and Sexual Health Center, which is run by Dr. Megan Bird, who’s fabulous. She’s a gynecologist with very special interest in gender surgery, gender care, and all things related to affirming care, up to the legislative level and administrative level.

Erin Everett:
Awesome.

Nick Esmonde:
If anybody’s asked about hormones, she manages hormones. She’ll also be working with us as part of our phalloplasty and metoidioplasty program as well.

Erin Everett:
Very cool.

Nick Esmonde:
Performing the vaginectomies. This probably didn’t come up organically here, but I’ll stick it in, maybe if you edit it however. It is important to know medical hard stops that we do not offer urethral lengthening without having a vaginectomy and hysterectomy performed first, due to the unacceptably high risk of urinary complications that come with that, among other reasons.

Erin Everett:
I actually read about those complications too. That is definitely something that we can probably intersect into your staging conversation.

Nick Esmonde:
Perfect. It’s just one of those things that people ask every now and then. I had someone the other day said they wanted phalloplasty, they absolutely wanted to keep their vagina, because maybe they wanted to have kids at some point. I said, “Great. You could always do a phalloplasty. You could have a phallus, not touch anything else for now. Then after you have kids, go back.” Of course, again …

Erin Everett:
That’s cool. I guess maybe even some people who identify as nonbinary would be interested in that as well.

Nick Esmonde:
There’s even now more published reports out there about what nonbinary patients are asking for in contrast to patients that are specifically requesting things for gender surgery. We’re now seeing some new requests or preferences or circumstances that then we say, “Okay. As long as it’s safe and everybody’s on board …”

Erin Everett:
Awesome. Very cool. Thanks again so much. Remember, everybody, stay fierce and live your truth.