GRS / SRS
(MTF) Why did you move to California, and why do you still maintain the administrative office in Trinidad, Colorado?
Dr. Bowers relocated to California for several reasons, but a primary one was difficulty with the administration in the Trinidad hospital. It became increasingly difficult to do her work there. The office is still maintained in Trinidad because Janet and Robin (her only employees at the Trinidad office), have worked for Dr. Bowers for 10 years, and 6 years respectively and were unable to relocated to California. They both have family and deep roots in the Trinidad area, but wanted to continue to work with Dr. Bowers. Dr. Bowers also wanted to maintain some continuity for patients when the practice moved to California. The patients continue to hear familiar voices and Dr. Bowers did not have to retrain a completely new staff in California. The long-distance administrative office is working well, as nearly everything that is done in terms of scheduling and patient contact has been done through email and phones, even before the move.
(MTF) My doctor says I have granulation tissue. Can you offer any advice about treatment?
The best advice regarding granulation tissue is simple excision with iris scissors. This can be done without anesthesia, as it usually doesn't hurt but will bleed slightly. Treat bleeding with silver nitrate. (Dec08).
(MTF) My doctor isn't very knowledgeable about transgender care. What is a standard hormone regimen when beginning hormone therapy?
Your doctor will need to review your medical history, monitor your electrolytes and perform LFT's at 3 months and annually. He or she may also perform other tests depending on your specific health conditions. Generally, your doctor can prescribe Estradiol 2mg 2-3 po q day, along with Spironolactone 100-200mg po q day BID (divided dosing). If your doctor has any concerns or questions, he or she may contact Dr. Bowers directly on Monday afternoons and Thursday mornings. (Nov08)
(MTF) Which complications are most common?
During the first 48 hours following surgery, bleeding from the exposed urethral portions happens occasionally. Pressure and ice are the best defense here. If your pad soaks through, notify your nurse. Nursing will check this frequently though you can be of help! The dressing is changed and pressure re-applied. If you bleed through the second dressing change (1 in 12-15 patients) your nurse will likely contact Dr. Bowers, who may place an additional suture at your bedside. (Sept08)
(FTM) Which GRS technique should I use?
Dr. Bowers performs a simple metoidioplasty and a ring metoidioplasty. The simple meta is great for thin-to-medium build guys who seek a near complication-free procedure that looks great, can be used for penetration, retains full sensation and allows GRS completion for documentation changes. It is also completed outpatient. The ring meta offers similar results but with the advantage of allowing guys to stand to pee though their new equipment. The disadvantages of the ring meta are that it is a much more difficult procedure to perform, requires hospitalization (2-4 days), has more potential complications (urethral fistula, stricture) and nearly (but not completely) obliterates the vagina. I prefer the ring over other metas with urinary hook-up because it does NOT require vaginectomy.
Phalloplasty is still the best GRS procedure for gentleman that heavy with significant pelvic/pubic fat (which would obscure the more modest meta results).
Where Can I Find a Therapist?
We are also attempting to accumulate a database of trans-friendly doctors and providers by region. If you need help finding someone, please call the office and we may be able to help.
Do you recommend using Arnica Montana or other supplements prior to or after surgery?
Arnica Montana is useful for reducing swelling, although our current surgical technique has been most responsible for reduced swelling. You can start Arnica Montana after the surgery while still in the hospital. Dr. Bowers does not recommend using Arnica Montana, or any other supplements prior to surgery.
(MTF) Does Dr. Bowers remove the prostate?
If this is not a normal procedure what are the reasons for leaving the prostate in?
The prostate shrinks so remarkably on Estrogen that, in my opinion, it does not deserve worry after surgery. I do recommend one PSA (Prostate Specific Antigen) performed one year after surgery. During surgery, we go THROUGH the prostate but do not and cannot remove it. There are many recommendations for post-ops to have their prostates examined (just as some recommend pap smears for MTF's). I believe, both recommendations are odd/alarmist and do not fully account for the physiology of the cancers they are trying to detect. So long as a post-op remains on estrogen, there is very little worry about prostate cancer. If the prostate does need examined, it lies in front of the vagina. Therefore, it should be issued vaginally, not rectally.
(FTM) Does Dr. Bowers perform chest surgery for FTM patients? If not, can she recommend someone?
Dr. Bowers does not perform chest surgery. She recommends the following surgeons:
(MTF) How safe is long term HRT for transsexual women?
There are great controversies regarding HRT. I, for one, am not fearful of the stuff. The studies done so far really do not test the 'best' HRT, that of a plant-based estradiol type formulation. Most all of the testing (and fear) is regarding Premarin, the HRT gold standard for many years which is conjugated equine estrogen extracted from the urine of chained pregnant mare's urine. I have always considered this stuff karmically unhealthy (I am also a vegetarian) and have never preferentially prescribed this stuff during my 20+ year career.
Because there is no pharmaceutical backing, plant-based estradiol is not studied and is most certainly NOT the same as Premarin. Furthermore the studies that ARE out there still show benefit for Premarin alone but have concerns more when Premarin is combined with Medroxyprogesterone (Provera). Again, natural plant-based Progesterone (Prometrium) is not studied....go figure.
As for the length of time that a post-operative woman should take HRT, that is not known but, I would think, at least into a person's early 70's (which is completely arbitrary at this point). I would suggest the lowest comfortable dose until further data does come in. Furthermore, consider animal fat intake as the primary etiology in breast cancer causation. (Sept08)
(MTF) Do I really need to do hair removal in the genital area prior to GRS?
Technically, no, as we do a follicle scraping and intra-operative electrolysis at the time of surgery. However, no matter how we try, this is likely to be incomplete and hair is likely to grow within the vagina if it is not cleared ahead of time (hair grows in cycles, as you know!). The areas of concentration should be (see website diagram) the shaft down to the base and the inner two-thirds of the central scrotum (i.e. leave the outer third as it forms the labia major and hair is an excellent camouflage for surgical scarring!). The clearing can extend all the way back to the anal area although it tapers down to a point in this area in terms of what is used during surgery. (Sept08)
(MTF) Will I need a labiaplasty following my GRS?
Normally, no. The so-called 'one-stage' appraoch was a primary goal of mine when taking over the surgery details from Dr. Biber in 2003. From both a cosmetic and hassle-related standpoint, the one-stage procedure offers great improvement over previous 'two-stage' techniques, in my opinion as a gynecologist. As a result, it also lowers the total cost for GRS by requiring only one procedure. That said, the primary GRS procedure is enormously difficult to perform, particularly given the differences in individual anatomy. Fewer than 20 secondary labiaplasties have been performed in more than 550 one-stage procedures. These have been done for primarily cosmetic reasons, not functional ones. (Sept08)
(MTF) How many GRS/SRS procedures has Dr. Bowers actually performed?
Dr. Bowers began to work with Dr. Biber in Jan 2003. She has been performing these surgeries exclusively, since July 2003. All told, she has performed nearly 900 primary GRS/SRS surgeries (as of October 2011) - along with 15 years of experience with labiaplasties and FTM surgeries. Tracheal shaving and breast augmentation are also related surgeries that Dr. Bowers does well. Most importantly, she brings her 20+ years of pelvic surgery experience to GRS/SRS, having already made significant modifications to Dr. Biber's technique since taking over. (Nov 2010)
Help! I've lost my Surgical Declaration Letter
We want you to leave California with this essential document in hand. For additional copies, or if yours gets lost, destroyed, or tied up in the legal system, we’re happy to notarize additional documents for a nominal fee of $20 per copy. (Nov 2010)
(MTF) I am considering having an orchiectomy for androgen supressionbut I really don't want to complicate my SRS surgery. What kinds of issues could having an orchiectomy before SRS, and are there ways to minimize the possible complications?
This is my most Frequently Asked Question these days, so I hope to answer it once and for all. I counsel against orchiectomy, as it drains money which could go towards SRS, unless this is your final destination (as it is for some individuals who, for health or personal reasons, never plan on SRS).
We've found spironolactone online for 0.50 cents / 100mG dose. At a typical pre-op dosage of 200mG/day, that is $30 per month. Even at a bargain basement $1000 for an outpatient orchiectomy (not recommended), the breakeven point is 3 YEARS. So unless you have some serious health issues that preclude taking testosterone blockers or are planning to have surgery 4-5 years down the road, an orchiectomy is going to cost you more money than simply taking the meds and saving your money. (27Jan04)
(MTF) Do I need to go off my hormones before surgery?
No, not really. I do like people to get down to a dose no greater than estradiol 2 mg daily about 2 weeks before surgery (that will be your ongoing dose following surgery anyhow). This is a time-honored torture that no one has ever questioned (let alone, asked a gynecologist about). The effects on blood-clotting are minimal; the avoidance of blood clots is handled in ways completely unrelated to hormones. However, we do request that you stop other medications (i.e. - progesterone, spironolactone, etc. ) two weeks before your surgery. (10Aug03)
(MTF) Will my clitoris be sensory?
Earlier surgeons such as Dr.â€™s Biber and Schrang made clitorises from a portion of the urethra rather than the glans. Those pseudo clitorises did have sensation but were not of the intensity that a natal clitoris has (and deserves!). Using the glans and dorsal neurovasculature was Dr. Bowersâ€™ earliest modification to Dr. Biberâ€™s surgery and is crucial. (Sept08)
(MTF) Will I be able to orgasm after surgery?
Although Dr. Biber and Schrangâ€™s patients reported high rates of orgasm, the dorsal nerve/glans combination has proven highly effective. Patients report a greater than 90% rate of orgasm, much of which depends upon good sexual health prior to surgery. (Sept08)
(MTF) What sort of breast augmentation technique(s) do you prefer?
We do saline implants, using a circumareolar or inframammary (below the breast) incision but place them in front of the muscle. Natal breast tissue does not lie beneath the muscle, it lies in front. The chief advantage in placing behind the muscle is that it requires less precision to keep the implant from shifting before a capsule (scar tissue) can hold it in place. If placement is accurate from the start, the implant will look good and stay where it ought to. Saline implants may also require replacement after 10 years.
We do place breast implants occasionally beneath the muscle (retro-pectoral) but generally only when insufficient breast development has taken place with hormones. In general, the retro pectoral location is considerably more painful and does not enhance the visual results when there is sufficient pre-operative breast tissue.
We also offer silicone (MemoryGel Implants). The look and feel of silicone is better but in most cases requires an inframammary incision of approximately 5cm. (Sept08)
If you have a question for Dr. Bowers that you would like to see answered here, please drop her an email.
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