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location:  Transition  >  Bottom Surgery  >  Consultations  >  Consult with Dr. Meltzer The following information is what I gathered from a metoidioplasty consultation with Dr. Meltzer in Burlington, MA at the First Event 2007 conference on January 20, 2007. My intention with this write-up is to simply present what I learned from speaking with him and is in no way meant to be a substitute for others having personal consultations with Dr. Meltzer. Dr. Toby Meltzer Dr. Toby Meltzer graduated from LSU Medical School in 1983 and is board certified in both General and Plastic Surgery. He is a member of the American Society of Plastic and Reconstructive Surgeons. In 2003 he moved to his present location in Scottsdale, Arizona, USA. He has privileges at Scottsdale Healthcare Osborn Campus at the Greenbaum Surgery Center. Overall, 95% of his practice consists of GRS surgeries, both FTM and MTF, and about 50% of these are genital surgeries. He performed his first GRS surgery in 1990 and since then has done about 300 metoidioplasties in total (I did not ask how many included urethroplasty). General Dr. Meltzer's FTM surgical formal presentation at the conference focused a lot on pumping and his attempts at enlarging the corporal bodies (erectile tissues) by use of an expansion device and by surgically joining the two separate corpus cavernosa (2 separate tubular erectile tissue areas) into one large erectile tissue area to facilitate getting a harder erection after surgery. So most of the information about his metoidioplasty procedure is from the private consultation after his presentation. Dr. Meltzer believes FTM genital surgery should be done with a team of surgeons: plastic surgeon, urologist, and gynecologist. With the cooperation of these other surgeons, he performs metoidioplasty, vaginectomy, urethroplasty, and scrotoplasty in 2 or 3 stages. Surgery - 1st Stage Vaginectomy The vaginectomy is performed by an OB/GYN surgeon, not Dr. Meltzer. All vaginal mucosa is removed, except a small amount used in the urethroplasty. This is the most risky part of the surgery in terms of blood loss. Urethroplasty The urethroplasty is performed by board-cerified urologist Dr. Mitchell Kay, who is the Urology Head at Scottsdale Healthcare Osborn. The new urethra is made from the urethral plate, vaginal mucosa, and the labia minora. One benefit of using vaginal mucosa in the new urethra is that it self-lubricates during arousal, acting as a "pre-ejaculate." Dr. Meltzer claimed they have the "lowest complication rate around," saying they've had 2 fistulas, 2-3 strictures, and 2 diverticula from when buccal mucosa was used. Metoidioplasty During the metoidioplasty, Dr. Meltzer removes the dorsal suspensory ligament of the clitoris to allow it to obtain a straighter position. The labia minora are removed, and some of this tissue is used for the urethroplasty. Surgery is performed at the Scottsdale Healthcare Greenbaum Specialty Hospital, and you are required to stay 2 nights in the hospital. A suprapubic catheter is placed during surgery and remains for about 12 days. A catheter in the new urethra is also placed during surgery and remains in place for 12 days. After 12 days, the catheter in the new urethra is removed, and you can begin urinating through the new urethra. If everything seems to be OK, the suprapubic catheter is removed, and you can return home. Post-op After hospitalization for surgery, you must rent a hotel and stay in the Scottsdale area for about 2 weeks. He does not recommend dilator use in the new urethra by the patient themselves, and if a stricture is formed, he (or his colleague) will be the one applying the dilator therapy. Scrotoplasty is not performed during this time, as the testicular implants may erode the new urethra. Dr. Meltzer said that he wants the new urethra to be more durable before inserting the testicular implants. Surgery - 2nd Stage Scrotoplasty The labia majora are brought to the midline and joined in the middle to create a joined scrotal sac. Either expanders or small-sized testicular implants are placed in each labia majora to create testicles. If expanders are placed, they are slowly enlarged over 3 months, at which time the permanent testicular implants are placed (3rd Stage). He does not use expanders with ports, as they may have a larger risk for infection; instead, you must insert a needle into the scrotum each time you want to enlarge the expander. Recently, he has been putting the small-sized testicular implants in (instead of expanders), and patients have been happy with that size, feeling no need to replace them with larger ones (though he will replace the smaller implants with larger ones at a later date if desired). They use Silimed soft silicone testicular implants from the United States. Dr. Meltzer did not know the size of the small-sized implants, but guessed they were about 25cc each. Post-op If he does a simultaneous mons resection, he requires you to stay 1 night in the hospital. Otherwise, you can return to the hotel after the scrotoplasty and placement of implants or expanders (given you have someone to drive you - if you are alone, you must stay 1 night in the hospital). This surgery occurs 3 months after Stage 1 and can either take place in the hospital under IV sedation or at the clinic under local anesthesia. Surgery - 3rd Stage Insertion of Permanent Testicular Prostheses If testicular expanders were placed during Stage 2, he will insert the permanent testicular prostheses. If mons resection was not performed during Stage 2, he can also perform one during this procedure. This surgery occurs 3 months after Stage 2. In addition, some patients opt for a "touch-up" surgery to bring the scrotum to a lower position or to close the midline of the scrotum if it has not descended low enough on its own over a couple of months. Scar Tissue When asked about post-surgical scar tissue development and subsequent disruption of scar tissue due to the multiple-stages, Dr. Meltzer said they leave the current scars and do cause them to get bigger with more surgeries. He claimed the larger scars serve to augment the blood supply to the area on which surgery was just performed. Revisions/Complication Corrections Dr. Meltzer himself does not charge for additional surgeries to fix any complications. However, the hospital has set-price revision fees, and if general anesthesia is required you must also pay for the anesthesia. If you need to see another doctor, he is willing to give the medical report to your new doctor. Cost The Stage 1 surgery (metoidioplasty, vaginectomy and urethroplasty) costs $29,144 USD. The Stage 2 surgery (scrotoplasty and insertion of implants or expanders) costs $4,350 USD if done in the clinic under local anesthesia or $5,173 if done in the hospital under IV sedation. An additional $477 USD is charged for Stage 2 if you have to stay overnight in the hospital (if you are having the mons resection or if you are alone). I don't think this Stage 2 price includes the mons resection surgery. I did not ask how much Stage 3 would cost. A deposit of $750 USD is required to hold Dr. Meltzer's fee for 12 months. They told me these prices are valid through July 1, 2007, at which time the hospital and anesthesia will increase in price. Other Dr. Meltzer will perform liposuction at the same time as Stage 1 or Stage 2 if desired; he said sometimes it is actually necessary in order to get a better result, and he does not see anything that would contraindicate doing liposuction at the same time as the other surgeries. He would recommend a mons resection for the vast majority of patients, because he thinks anyone could benefit from it unless you are extremely thin. When asked about the "free-up" only procedure, he said he would do this procedure, but only in preparation for a later metoidioplasty. He believes the free-up procedure may allow for easier pumping before the eventual metoidioplasty. Dr. Meltzer recommends pumping before surgery, and suggested a pump or constricting device (such as a cockring) could be worn for up to 2 hours on the genitals (making sure to be aware of any contraindicating pain or bluish color of the skin). He said he has not seen a change in results with the use of testosterone cream on the genitals before surgery.