The hospital staff is courteous, friendly and competent and
although they will be as helpful as possible, any technical questions
regarding the surgery are best reserved for me.
It is most important to prepare the patient both inside and out,
therefore, you will be given a thorough bowel prep to make the inside
of your body as clean as possible for the operation. You will be asked
to take a shower with a shampoo. There will be a perineal and perianal
prep which amounts to having those areas shaved. This will be followed
by painting the middle part of your body with an antiseptic solution
to keep the bacteria count down. A liquid supper is served around 6:00
p.m. and you will be given a sleeping pill around 10:00 p.m.
In the morning you will be given your pre-operative medication
which will make you feel groggy. You will then be taken down to the
operating suite where a general anesthetic will be administered. You
will remember nothing until you wake up in the recovery room.
Depending on what is done, the operation can last anywhere from
three to five hours. If you are having additional work such as a skin
graft, more time, of course, is required.
It is important that you know about a basic fundamental problem
regarding the depth of your new vagina. I try to make the neo-vagina
as deep as I can - up to six or seven inches is common and obviously,
the longer your penis, the more skin will be available to line this
newly created opening. Sometimes however, the new vagina may not end
up being as deep as one would like. If future sexual intercourse is in
your plans, and your penile length is adequate, the standard genital
procedure without a skin graft would be done. On the other hand, if
your penis has relatively little length, I would suggest that a skin
graft be used to help make the vagina deeper, unless of course, you
have NO plans for future intercourse. The skin graft comes from the
area beneath the umbilicus and above the pubic hair or it can be taken
from the thigh or buttocks. The donor site does leave a mark and is
noticeable. The determination whether or not to use an ancillary skin
graft would be made at the time of the physical examination. In
general, the shorter your penis and the greater your desire for future
intercourse, the more likely a skin graft would be considered. If you
have a relatively short penis and insist on SRS without a skin graft,
the inadequate depth of your vagina for future intercourse must of
necessity be YOUR RESPONSIBILITY.
The question of secondary scarring from the skin graft donor site
is always raised... Yes, there is a mark where the skin graft is
removed. The color of this area varies in intensity from person to
person and in some patients it can become red, raised and last a long
time. Although it invariably fades out in time, this involution
process can be hastened by applying sheets of silicone to the area for
several months. Again, the response of this new technology varies from
patient to patient.
We expect our results to be good to excellent; however,
complications can occur. Although most problems can be readily and
successfully dealt with, the Recto-Vaginal fistula is the most serious
possible problem that could happen. Should the rectum be inadvertently
entered, the opening would be closed, but a future fistula could
result. Your bowels are cleansed thoroughly before surgery to prevent
this problem but if a fistula does form, it would be necessary to do a
temporary diverting Colostomy until the fistula could be adequately
closed at a later date. Keep in mind that the dissection of the
Neo-vagina is delicate and hazardous with the possibility of rectal
damage always present.
I WANT TO EMPHASIZE AS STRONGLY AS I CAN THAT THE FIRST SURGEON TO
DO THE SRS WITH OR WITHOUT A SKIN GRAFT HAS THE BEST CHANCE FOR
SUCCESS. Experience has taught us that redo's to deepen the vagina can
be (but are not necessarily) very difficult and run the risk of being
unsuccessful. The rectum could be entered due to the fact that scar
tissue is present in the deep vagina making secondary dissection
perilous. Once the secondary dissection is complete, a skin graft must
be used to line the newly created, deep vaginal area which had
previously contracted. This newly created opening has the TENDENCY AND
GREAT ABILITY to contract again and obliterate itself in spite of
diligent dilating on the part of the patient resulting in NOTHING
GAINED. Therefore, we suggest for anyone who has had SRS done
elsewhere and develops a vaginal contracture that they return to their
original surgeon for treatment.
While in the recovery room, we make every effort to avoid the
feeling of nausea and vomiting which we do with both drugs and the
administration of oxygen. You will have a Foley catheter in your
bladder which may give you a feeling of wanting to urinate. This
feeling will pass. Once you are awake, you will be returned to your
room where you will sleep for much of the remaining day. The IV in
your arm usually stays until you no longer have pain which is about
five to six days. Your pain medication (Demerol or Morphine) is given
through the IV. Sleeping pills will be given every night that you are
in the hospital.
Not counting the day of surgery, you will be confined to bed for
six days. For example, if your surgery is on Tuesday, you will not be
able to get up and out of bed until the following Monday. Since this
may seem like a long time to you, it is best that you bring reading
material or paper work to occupy your time.
Constipation is not unusual and you may not have your first bowel
movement for three or four days. Of course, it will be necessary for
you to use a bed pan as we cannot allow you out of bed until more
healing has occurred.
Ice packs will be applied to your groins continuously; your
sanitary napkins will be changed as necessary and sponge baths will be
given while you are in bed. You will find a wire tied over cotton in
your pubic area this along with your urinary catheter will be removed
on the sixth day after which you will take a shower or bath when your
strength has returned. At first you will feel weak, but your strength
will recover rather quickly. If urination is difficult, it is because
of swelling and the presence of the vaginal pack. Should you be unable
to urinate, the catheter will be temporarily replaced.
You will be leaving the hospital on the eighth day. For example, if
your surgery was done on Tuesday, you will be discharged on Wednesday
of the following week. The day you leave, your vaginal packing will be
removed and you will receive instructions as to how to keep your own
vagina dilated. If you are sent home on additional drugs, they can be
obtained at the hospital pharmacy but be prepared to bring enough
money to cover costs. In order to make your trip home easier and more
pleasant, especially if you live far away, we STRONGLY SUGGEST that
you stay in one of the area hotels for several days after your
hospital discharge. Because we have experienced non-payment of our
fees in the past, we have formulated the following fee policy. If you
consult with me in my office any time other than the day before your
surgery, I charge $75.00 for this time and this $75.00 is to be paid
IN ADVANCE BEFORE YOUR OFFICE CONSULTATION IS SCHEDULED. To avoid
cancellations, no shows and people who are not serious, this fee is
NONREFUNDABLE. The basic fee for the genital surgery is $4750.00. If
your penis is so small as to warrant a skin graft procedure along with
the usual inversion technique, there will be an additional $500.00
charge.
Once we set a surgical date, whether or not you have been seen by
me in my office, we require a $500.00 deposit to reserve that time.
The $500.00 is to be received in our office NO LATER THAN ONE WEEK
FROM THE DATE THAT YOUR SURGERY IS SCHEDULED. Once we set the surgery
date and you cancel for any reason whatsoever, the $500.00 is
ABSOLUTELY NONREFUNDABLE . The only exception to this would be if I
determine, at the time I first see you in my office, that you are not
a candidate for transsexual surgery. Only then will your $500.00 be
refunded. Remember, the $500.00 advance deposit is to secure your
surgical time. If your deposit is not received per our office policy,
you may lose you surgery date to someone else.The remainder of your
bill is to be paid at least two weeks prior to your surgery and NO
PERSONAL CHECKS PLEASE.
Hospital and anesthesia fees MUST LIKEWISE BE PAID IN ADVANCE.
Please have separate cashier's checks made out to each provider in the
designated amount. The hospital fee is $5,400.00 and should be made
out to Theda Clark Regional Medical Center. The anesthesia fee is
$924.00 and should be made out to the Association of Hospital
Anesthesiologists, Inc.
The following is our basic fee schedule including the other
ancillary operations done to feminize the face, chest and genitalia:
SURGERY SURGERY HOSPITAL *** ANESTHESIA***
PROCEDURE Sched. A* Sched.B**
Genital Surgery (SRS) $ 4,750.00 $4,950.00 $5,400.00*^ $890.00
SRS with Aug Mam 5,850.00 6,100.00 6,000.00*^ 1,117.00
SRS with skin graft 5,250.00 5,450.00 5,400.00*^ 924.00
SRS w/graft & Aug Mam 6,350.00 6,550.00 6,000.00*^ 1,151.00
Later deepening of 7,750.00 8,050.00 5,400.00 920.00
Vagina with skin graft
(for stenosis)
Chin shave 1,500.00 1,600.00 250.00 160.00
Orchiectomy
unilateral 1,000.00 1,200.00 510.00 450.00
bilateral 1,700.00 1,800.00 510.00 450.00
Labiaplasty 1,500.00 1,750.00 750.00 452.00
Tracheal Shave 1,300.00 1,400.00 510.00 452.00
Malar Implants 1,300.00 1,400.00 670.00 452.00
Augmentation 2,200.00 2,300.00 680.00 454.00
Mammaplasty
Implant fees are not quoted due to constantly changing prices. They
are sold to you by us-not the hospital--- at our cost in order to keep
the price down for you.
Total Reduction 3,600.00 3,800.00 1,450.00 636.00
Mammaplasty (Female to Male)
Testicular Implants 1,200.00 1,300.00 250.00 160.00
* Schedule A - Surgical fee if paid by cash, (cashiers check or
money order) and RECEIVED BEFORE OR NO LATER THAN 14 DAYS PRIOR TO
SURGERY.
** SCHEDULE B - Surgical fee if received WITHIN the 14 days prior
to surgery or if paid by any means other than cash.
*** If you wish to pay the hospital and/or anesthesia by any means
other than cash, such as by credit card, you must contact them for
permission to do so.
*^ - There has been an increase in the prepay hospital fee which
allows for coverage of unexpected hospital expenses incurred over and
above the usual charges. However, should your operative and
post-operative courses be uneventful and you do not require additional
costly medical care or if you are medically able to be discharged one
day early, a rebate in an amount up to $600.00 will be refunded to you
within five working days after you are discharged. In the past, added
expenses were absorbed by the hospital and the patient was never
billed for them; now, the hospital can be covered without having to
collect from the patient after she returns home.
If procedures are staged, such as orchiectomy followed later by
SRS, the initial procedure will be full price. When the second
procedure is scheduled a price break will be given; we will reduce the
SRS fee by subtracting 1/2 the price of the initial procedure. This
policy applies ONLY if the initial procedure was done by me. If done
by someone else, the FULL PRICE for SRS will still be charged.
Regarding Secondary Genital surgery to correct problems from a
previous operation; experience has taught us that Sex Reassignment
Surgery to correct cosmetic or functional problems occurring at the
time of or after the first surgery are FAR MORE DIFFICULT the second
time it is done because distorted anatomy and scar tissue interfere
with meticulous surgical dissection. Complications such as operative
and post-operative bleeding are more common and patient stay in the
hospital can be prolonged over the usual 8 days. For these reasons,
the surgical fee for an SRS redo is $7,750.00. The hospital and
anesthesia fees will be the same as primary SRS, HOWEVER, there may
also be INCREASED OR ADDED HOSPITAL, ANESTHESIA AND SURGICAL CHARGES
if complications arise necessitating more surgery or if the eight day
stay is exceeded.
Any additional charges will be the patient's responsibility, so
please come prepared to pay these extra costs at the time of your
discharge. I will continue to be responsible for my own patients and
will do whatever I can to improve upon any complications that may have
arisen from surgery that I have performed. This however, does not make
the degree of difficulty of any additional procedure less, but I would
prefer that other surgeons deal with their own complications.
If more than one operation is done (for example: Genital
Transformation plus Augmentation Mammaplasty), it is customary for the
surgeon and the anesthesiologist to cut the cost of the lesser
procedure in half. However, this is NOT the policy of the hospital;
their fees are additive because they have already discounted their
prices well below the standard going rates as a special favor to
cosmetic and transsexual patients.
Please remember that all hospital quotations for ANCILLARY cosmetic
and transsexual surgery are for ONE DAY STAY ONLY. There is an
additional $80 charge to stay overnight if I feel it is medically
necessary for you to be observed for another 12 hours;the charge will
increase to $225.00 if you elect to stay overnight for no other reason
than it would be a convenience for you. If you remain in the hospital
longer than 24 hours, - No matter what the reason - your quoted fees
will no longer apply and you will be charged A GREAT DEAL MORE than
those original quotations. Therefore I suggest you limit the
procedures you want to a reasonable number. There is a limit to how
many different operations I can do on one person at any one time. I
will determine how much surgery will be judicious and prudent on a one
day stay basis.
ALL FEES ARE SUBJECT TO CHANGE. Regarding insurance - experience
has taught us that insurance does not pay for cosmetic surgery nor
gender dysphoria problems. There is, however, always that rare
exception but since the hassle with insurance companies is so great,
we ask that if you have insurance which will cover your procedure,
PLEASE HAVE THIS FACT NOTED IN WRITING from your insurance company and
we will then, and only then, SEND WHAT FORMS YOU GIVE TO US into the
insurance company. However, WE WILL STILL ASK FOR PAYMENT IN ADVANCE
and any monies received from insurance companies will be refunded to
you.
Lastly, please do not ask this office to send letters to insurance
companies trying to convince them that your problem is medically
necessary. This is just the hassle we wish to avoid. We suggest that
this be done in advance of your being seen by me. The matter of the
overweight patient has come up on a number of occasions. Without
having seen you prior to surgery, it is impossible for me to determine
the feasibility of doing your surgery if you are markedly overweight.
SRS can be done on most people, however in the morbidly obese, the
operation is still very difficult and the final results are
compromised because of the presence of great amounts of fat tissue.
Overweight people simply do not do well during and following surgery
and the results of our efforts are not as good as they would be if the
person were of normal weight. Some obesity can be dealt with, but I
just want to emphasize that anyone over 200 pounds may have a very
difficult time. I realize that 200 pounds on someone over 6 feet is
not a problem, but 200 pounds on someone 5 feet tall is a weight
problem very difficult for any surgeon to overcome. The final
determination of whether or not your surgery can be performed because
of your relative weight, will be determined at the time of your
physical examination. If you are markedly overweight, do not be
disappointed if your surgery is postponed giving you a chance to lose
some excess poundage.
Much discussion has evolved around the discontinuing of hormone
therapy prior to SRS surgery. When the genetic female undergoes
routine surgery, nature has provided protective mechanisms (not
entirely understood) against the formation of thrombotic emboli (which
can cause death) that are not present in the genetic male taking
female hormones. Therefore, even though the likelihood of this dreaded
eventuality is remote, we STRONGLY RECOMMEND for your own safety, that
you discontinue taking hormones three weeks prior to and three weeks
after your surgery - ANY SURGERY! Withdrawal symptoms are
uncomfortable, but temporary, and much better than dying. Also, please
stop taking Aspirin as well.
Since the operation cannot be completed in one stage, some patients
elect to have the Labiaplasty portion done three months later. This is
intended to feminize the operated area and cannot be done at the time
of the SRS because important blood supply would be cut off from vital
tissue. Whether or not to have the Labiaplasty is your option.
Because we live in an age of high technology, computers, etc., it
has unfortunately come to our attention that psychological evaluations
can be and have been falsified. Since we have no way of knowing the
credentials of very psychologist and psychiatrist who refer patients
to us, we must CONFIRM the fact that you are indeed a candidate for
SRS. If your evaluations are in doubt, we will have our own Clinical
Behavioral Scientist evaluate you on a one time basis either at her
office in Chicago for $250.00 or, if it is more convenient for you, at
my office here in Neenah for which she charges $500.00. Because this
surgery is irreversible, we do not want you to enter into a situation
which you will later regret. Dr. Randi Ettner's interview will be on a
one time basis and keep in mind that this is necessary for your
protection as well as ours. If it so happens that you only have one
psychological workup, Dr. Ettner will be asked to evaluate you as a
second opinion which may take several sessions or even a complete
course of evaluation may be required. In any case, great weight will
be placed on her final recommendations.
Enclosed find a map of the area. If the Appleton Airport is used,
cab transportation is readily available by a phone conveniently
located in the airport. The number is (414) 832-8890 and the cost is
around $11.00, also, the Valley Inn provides shuttle service. If the
Green Bay Airport is used, patients have told us the "Fantasy
Limousine Service" for $45.00 would be less expensive than
renting a car since they take you to the hotel and it would not be
necessary to drop a rented car off at the airport. Their number is
(414) 730-3866.A copy of the Male to Female consent form is enclosed.
You may find it helpful.
Hopefully the above has provided adequate information, but if not,
please call our office and any one of us will gladly answer what
questions you may have. It is our sincere wish that your transsexual
operation will be a relatively pleasant experience and we will do
everything we can to make it so.
- Very sincerely yours,
Eugene A. Schrang. M.D.
GENDER DYSPHORIA
OFFICE POLICY INITIAL OFFICE CONSULTATION
We have established the following guidelines for setting an initial
consultation with Dr. Schrang. We ask that the patient to send the
following to our office when scheduling the initial consultation. No
operation of any kind to change a person's sex will be done until the
following are completed and/or received.
1. Name2. Address
4. Date of Birth5. Social Security number
- 6. $75.00 check for prepayment of pre-op consultation. The
$75.00 fee will be waived if the consultation is done the day
before surgery.
CHECKLIST FOR TRANSGENDER SURGERY
1. Letter confirming a year of hormone therapy from:
- Dr.______________________________________ ___
- Two Psychiatric Reports recommending SRS must be sent to our
office pre-operatively and will be verified.
3. Advance payments:
- A) $500.00 to secure operating room time. Due one week after
surgery is scheduled. ___
B) Balance of surgical, hospital & anesthesia fees due two
weeks in advance of surgery by three cashier's checks sent to our
office. ___
C) If implants (Mammary, malar, chin, testicular, etc.) are to be
used, advance payment for their purchase. ___
4. Signed consent form. ___INFORMED SURGICAL CONSENT AGREEMENT FOR
MALE TO FEMALE TRANSSEXUAL SURGERY
1. I, _________________________ hereby authorize Eugene A. Schrang,
M.D. to perform any or all of the following operations intended to
transform male anatomy into female anatomy: total penectomy (removal
of the penis), bilateral orchiectomy (removal of testes), construction
of a vagina from the penile skin and/or with a split thickness skin
graft in the area where the scrotum now exists, a clitoris and a new
urethral opening, labiaplasty, tracheal shave (reduction of tracheal
cartilage), revision of a previously constructed vagina and/or
urethra.
2. This operation has been explained to me by Dr. Eugene A. Schrang
and I understand the nature and consequences of the procedure. I
understand that during the course of the operation and/or medical
treatment, unforeseen conditions could become apparent that may
necessitate an extension of the original procedures or different
procedures than those set forth above. I therefore authorize and
request that Dr. Schrang perform such surgical procedures or render
such medical treatment as are necessary and desirable in the exercise
of professional judgment. The authority granted under this paragraph
shall extend to treating the conditions that are both known and
unknown to Dr. Schrang at the time the operation is commenced. I also
understand that it is impossible for a surgeon to disclose every
conceivable risk, however remote. Although good results are expected,
complications cannot be anticipated; therefore, there can be no
guarantee either expressed or implied, as to the result of this
surgery since the practice of medicine is not an exact science. The
following points have been made specifically clear and are intended to
provide information and not to cause alarm:
A. Scars result from any surgical procedure but, every effort is
made to conceal or make them as inconspicuous as possible
B. The signs of inflammation do occur such as tenderness, swelling
and discoloration (redness or black and blueness) which may last for
several weeks or until the wound is completely healed. Residual
swelling and redness can last a year or more.
C. Numbness in or around the operative site may occur and may
persist for an indefinite period of time. Occasionally this may be
permanent. Numbness may also occur in the hands, arms, or legs due to
the position of the body during surgery. This may or may not be
permanent.
D. Infection in the operative site, hematoma (local collections of
blood in the operative site), dehiscence (wound edge separation) could
possible occur. Severe bleeding after surgery may occur necessitating
a blood transfusion - you will be responsible for this additional
cost.
E. Unintentional interruption of blood supply to a flap, skin graft
or part of the operated area may result in its loss.
F. Asymmetry (noticeable difference in the size and shape) between
two sides of the operated area may result when both right and left
sides are operated upon.
G. Inadvertent entry into the rectum may occur which could
necessitate immediate closure of the opening; closure of whatever
vagina has been created; and the immediate closure of the opening; and
the immediate or later creation of a colostomy (exteriorization of the
colon in order waste does not pass through the rectum)
H. Inadvertent entrance into the urethra, urinary bladder or
peritoneal cavity is a possibility and could cause later scar
contracture or other unforeseeable problems in the future.
I. Although very rare, embolism from a blood clot may happen which
could result in death.
J Completely unpredictable and unusual complications, although
extremely rare, including even death may occur.
K. Shortening of the newly made vagina may occur secondary to scar
contracture deep within the vaginal vault. I understand that this
complication is generally due to failure on my part to diligently
dilate my new vagina.
L. The Tracheal procedure can result in hoarseness and deepening of
the voice which can, in some cases be permanent.
M. I understand that because of the nature of the above procedures,
it is impossible to predict all the possible psychiatric and
psychological results.
N. Some of the possible complications explained to me which can be
involved in these procedures include in addition to those set forth
above but not by way of limitation, are the following: severe loss of
blood, infection, cardiac arrest, poor cosmetic results, permanent
pain and discomfort, adverse affects from anesthesia, and psychiatric
disorders.
3. I understand this operation is totally irreversible and that I
no longer will be able to have intercourse as a male or to conceive
children, I also understand that Dr. Eugene A. Schrang does not
guarantee any sexual pleasure or function as a result of the above
stated procedures.
4. I consent to the administration of such anesthetics as may be
considered necessary or advisable by the physician or anesthetist
responsible for this service.
5. I consent to be photographed before, during and after treatment,
and understand that these photographs are the visual part of my
clinical record and are the property of Eugene A. Schrang, and may be
published in scientific journals and/or shown for professional
reasons.
6. I have been informed by Dr. Eugene A. Schrang that his
professional fee for this operation is $___________. I consent to pay
this amount which I understand includes the surgical procedure and all
postoperative hospital and office visits up to six months. This fee
does not include the hospital fee and anesthesiologist's fee,
preoperative office consultations and examinations and surgical
intervention to correct operative or postoperative complications.
7. I certify that I am not presently married and will not be
married prior to the operation contemplated herein or if I am, my wife
has signed the Spousal Release Form.
8. I certify that I have read and fully understand the above
consent and agreement which has been preceded by explanations by Dr.
Eugene A. Schrang. I also certify that I have read and understand Dr.
Schrang's standard form letter regarding Sex Reassignment Surgery. His
explanations in no way vary from the contents of this consent
statement or his form letter and are understood by me. I agree not to
revoke, limit or alter this consent except in writing delivered to Dr.
Schrang prior to commencement of the operation or procedures hereto
described:
I FULLY UNDERSTAND ALL OF THE ABOVE. I HAVE NO FURTHER QUESTIONS. I
DO AUTHORIZE EUGENE A. SCHRANG, M.D. TO PERFORM ANY OR ALL OF THE
PROCEDURES OUTLINED IN PARAGRAPH ONE, OR SPECIFICALLY THE FOLLOWING:
____________________ _____________________
Date Patient
Witness
