Frequently Asked Questions

A portion of the glans (head of the penis) with its nerve supply is converted into the clitoris. This sensitive clitoris maintains normal erogenous sexual sensation and allows my patients to have orgasms. Other techniques amputate the glans or invert it into the vagina, usually without maintaining normal sexual sensation; these procedures usually use spongy tissue surrounding the urethra to create a clitoris. During the clitoris creation, I use a small amount of penile skin just below the glans to create a clitoral hood. The testicles are removed.

The skin of the penis is inverted to create a vagina. The depth of the vagina is important to most patients, especially those desiring sexual intercourse. Traditionally, the depth of the vagina is determined by the amount of shaft skin. Since many patients with a smaller penis did not have adequate depth for satisfactory intercourse, they were often disappointed. Skin grafts from the lower flanks or sides were often used, but the graft donor site can cause unsightly scars. Therefore, I routinely use a skin graft from extra scrotal skin and attach it to the deepest part of the penile skin to make the vagina deeper. The skin must be hairless in order to prevent hair growth inside the vagina, so the hair is removed first by multiple electrolysis treatments. Occasionally, a patient may not have sufficient penile shaft skin or scrotal skin for a deep vagina, so flank skin is then also used. Usually this results in a linear scar.

The remaining scrotum is tailored to make the labia majora or outer lips, and various other techniques are used to create labia minora or inner lips. I also spend considerable time performing intricate maneuvers that give the genitalia a more normal appearance and minimize scars. I rarely perform secondary surgery to enhance the appearance, since most of my patients are very happy with their single stage operation.

The electrolysis treatments should be performed on the entire scrotum except for a small area on each side. This allows the use of the maximum amount of scrotal skin for the graft. Even if a scrotal skin graft is not needed, electrolysis should be performed on the area just below the scrotum on the midline. This skin is used as a flap to widen the vagina, so hair growth at this location can be uncomfortable or unsightly. A numbing cream can be used to lessen the discomfort from electrolysis. Laser hair removal is not considered permanent at this time, so it is not recommended. Later hair growth in the vagina can cause problems.

The procedure is performed in the same manner as using full thickness skin grafts, except the vagina is constructed from rectosigmoid colon instead of skin grafts. The advantage is that the vagina is lubricated and deep, whereas as major disadvantage is that it is a more invasive operation requiring entry into the abdominal cavity with bowel surgery.

Many patients from other surgeons seek improvement in the appearance of their genitalia. Each patient is different, because SRS techniques vary amongst surgeons. Examples of desired procedures are remodeling of the labia majora, creation of labia minora, creation of a clitoral hood, elimination of a concavity of depression in the pubic area, removal of spongy tissue around the urethra that enlarges with sexual stimulation, and set-back of the urethra. Each reconstruction is challenging but can be very rewarding for the patient. It is usually performed in the surgical center as an outpatient.

Some patients may have had narrowing or shortening of the vagina, which prevents sexual intercourse. Colon surgery to deepen and to widen the vagina is very invasive and requires removal of the previous graft or vagina. The procedure is difficult. I rarely perform colon surgery, because I have been very successful by adding full thickness skin grafts to make the vagina deeper. Incisions are made inside the vagina from the 3 to 9 o’clock location, the space is made deeper, and the skin graft is placed. The skin must be hairless, so it is usually taken from the lower abdomen. I do not use split thickness skin grafts, because they tend to contract and are more difficult to stretch. The surgery takes about 5 hours and requires 6 days in the hospital.

If you have any questions about transsexual surgery – male to female, please feel free to contact the Transgender Surgery Institute Of Southern California. .

I perform a metaidoioplasty (extend, straighten, and release the clitoris) but do not extend the urethra. I will straighten the new penis and insert testicle implants into the labia majora at the same time. I often remove excess pubic by liposuction or excision. I don’t do a urethral extension, which requires a hysterectomy, vaginectomy, etc, because it has a much higher complication rate. I also do not perform microsurgical free flap phalloplasty, such as making a penis from a forearm. Surgery is performed as an outpatient.

I perform a secondary reconstruction of other phalloplasties to improve appearance, correct urinary problems, or insert penile implants. The scrotum is constructed by various techniques including tissue expansion, insertion of testicle implants, muscle flaps, and grafts. Testicle implants made of saline of solid gel are available.

Female to male transgender patients need reductive surgery to create a male chest. The surgery depends on the size of the breasts, the amount of skin and the size and position of the nipples. For smaller breasts, sometimes a minimally invasive approach can be used. This technique uses a peri-areolar incision and liposuction to remove the breast tissue behind the nipple and to give a more masculine, flatter appearance to the chest.

For patients with larger breasts, the technique involves a completion mastectomy. The completion mastectomy involves a larger incision at the inframammary fold: the junction between the pectoralis muscle and abdomen. The nipples are usually reduced and made into a more elliptical pattern. They are then repositioned more superiorly (higher on the chest wall) and laterally (toward the arms) to give the appearance of a more masculine nipple shape and position. Liposuction can be combined to provide optimal chest contour.

The third technique is the keyhole pattern. This technique is rarely ever used due to the amount of scarring and lack of contour achieved in the chest.

Our surgeons make every effort to minimize the size and appearance of the scars to give the most aesthetically pleasing final result. There are many options to assist in the final appearance of the scars including scar gels, scar creams, silicone sheeting, and laser treatments.

Our surgeons do everything possible during the primary surgery to avoid the need for a revision, however, sometimes revisions are needed to improve contour, scarring or nipple distortion.

Male to female chest surgery typically requires constructive techniques. These techniques include the use of breast implants, local flaps, or fat grafting.

The most common technique typically involves placement of breast implants. The size and shape of the chest determine what type of implant is used in the augmentation. Ancillary techniques involve changing the nipple size or position depending on the desired result. The most common implant used is a silicone breast implant because it tends to give the patient a more natural look and feel. Saline implants can also be used, however risks of rippling and deflation are higher.

During the initial consultation with the surgeon, we will discuss the details of the procedure which include the approach, surgical technique and type of implant.

If the breast is distorted or deformed, more extensive surgery than a simple augmentation may be necessary to achieve the desired result.

In the genetic male, the eyebrows are usually positioned lower and the forehead bone is more prominent. An eyebrow lift and contouring of the forehead bone give a more feminine and softer appearance. This surgery is relatively minor with a low complication rate. Facelifts, rhinoplasty (nose), eyelid surgery, laser resurfacing, lip enlargement, and facial implants improve feminization. Liposuction, abdominoplasty, thigh lifts, etc. improve body contour. These procedures are usually performed as an outpatient.

Chin implants, rhinoplasty, and liposuction are among the procedures to improve appearance.

You usually need to remain in Los Angeles for at least a week after breast augmentation, facial surgery, and other procedures. I believe it is important that you do not leave town unless we are reasonably sure that no complications will occur.

The price for the different cosmetic procedures is determined by the operation necessary. Patients from outside the area are encouraged to send us photos, preferably on email as jpegs. Once these photos are obtained, Dr. Youssef will phone you for a consultation.