Dr. Lubos Kliniken - Andre konsultasjon om falloplastikk

Dette er en transkripsjon av min første konsultasjon om falloplastikk med Dr. Markovsky hos Dr. Lubos Kliniken Bogenhausen i Tyskland. For mer informasjon om klinikken, se Nedre kirurgi: Del 5 - De tyske klinikkene

Transkripsjonen er på engelsk. Under konsultasjonen ble det vist noen visuelle eksempler i form av bilder og/eller tegning på ark. Dette kommer dessverre ikke frem i transkripsjonen. Unødvendige ord og setninger har blitt fjernet i etterkant.

Her er lenker til alle konsultasjonene jeg har hatt i kronologisk rekkefølge:


Transkripsjon

Dersom du vil ha transkripsjonen i PDF-format kan den lastes ned her.

Sted: Dr. Lubos Kliniken Bogenhausen

Dato: 03.06.2024


00:00:06 Doctor
Hello.

00:00:08 Doctor
It is quite a time that we talk or that we saw each other, but it's not very long ago that I finally wrote something, right?

00:00:16 Levi
Yes, yes.

00:00:17 Levi
It's absolutely.

00:00:18 Levi
It wasn't any rush anyway, so.

00:00:20 Doctor
Yeah, you know, but I do not like it myself if I have some state, some things on my desk, but whatever.

00:00:29 Doctor
And me as a patient, I would not like it if I wait for something which is important for me.

00:00:35 Levi


00:00:36 Doctor
But anyhow, okay, so what can I do for you today?

00:00:40 Levi
Yes.

00:00:40 Levi
So since we last talked, I have a lot of new questions, and I have written them all down.

00:00:46 Levi
So if you don't mind, I'll just go through them one by one.

00:00:51 Levi
I have realized it's important to me to not bury my clitoris.

00:00:57 Levi
So what I'm wondering is, I don't think I asked this directly enough last time, but the setup that I want is no burial of the clitoris, no vaginectomy, but urethral lengthening.

00:01:10 Levi
Is that something you are comfortable doing?

00:01:14 Levi
In that case, I was also just wondering, where does the urethra go if it's not along the clitoris?

00:01:24 Doctor
The urethra stays in the place where it usually is.

00:01:29 Doctor
When we bury the clitoris, the clitoris goes out of the way.

00:01:34 Levi
Okay.

00:01:35 Levi
So it's just kind of pushed to the side or something?

00:01:37 Doctor
Pushed to the side or something.

00:01:42 Doctor
You have to know some things about that kind of procedure.

00:02:02 Doctor
Even with that procedure, we should do a urethral lengthening and a stretching mobilization of the clitoris in advance.

00:02:11 Levi
Okay.

00:02:12 Doctor
Not with the phalloplasty.

00:02:18 Doctor
We then need to dissect the preformed urethra from the clitoris.

00:02:33 Doctor
So this is potentially more damage to this new urethra and to the clitoris itself.

00:02:44 Levi
Oh, really?

00:02:45 Doctor
If we.

00:02:47 Doctor
If we compare it with a clit pen, with a deepithelialized clitoris, which is buried.

00:02:58 Levi
Right.

00:02:59 Doctor
Because we need to divide the urethra from the clitoris.

00:03:02 Levi
Yeah.

00:03:03 Levi
Okay.

00:03:03 Doctor
Because the urethra should go along in the middle and the clitoris needs to move to the side.

00:03:09 Doctor
So we need to dissect that a bit, that we have some tissue that can go to the side.

00:03:21 Levi
What are the consequences for the clitoris then?

00:03:24 Doctor
Maybe more damage to the tissue and to the nerves, maybe less sensitivity.

00:03:31 Levi
Right.

00:03:32 Levi
Okay.

00:03:33 Levi
I didn't know that.

00:03:34 Levi
That's because the reason that I want to preserve the clitoris is because I'm scared of losing sensation in my genitals.

00:03:41 Doctor
Yeah.

00:03:42 Doctor
So I do not have a picture with a clitoris out with a non buried clitoris, but I can I can simulate somehow.

00:03:57 Doctor
Let me see.

00:03:59 Doctor
[Draws on paper]

00:04:12 Doctor
So this will be the situation after the phalloplasty with a buried clitoris.

00:04:18 Levi
Right.

00:04:19 Doctor
And because we want to have the unithra in the middle with no dangerous tissue above it.

00:04:27 Doctor
Because if there's some problem with the urethra, we need to cut in the middle.

00:04:31 Levi
Right.

00:04:31 Doctor
So this is why we need to move the clitoris to the side.

00:04:35 Doctor
Okay.

00:04:36 Doctor
Clitoris behind the urethra.

00:04:39 Doctor
So the clitoris would be maybe, depending on how long it is, how long we can prepare or prepare a pedicle to move it to the side.

00:04:53 Doctor
It would be somewhere here.

00:04:56 Doctor
It was here.

00:04:57 Doctor
And then maybe it would be here or here or here.

00:05:01 Doctor
Somewhere at the side of the scrotum or at the base of the phallus.

00:05:10 Levi
Right.

00:05:12 Doctor
And it will look like the clitoris looks like now.

00:05:17 Levi
Right.

00:05:18 Levi
But will it be visible when everything is hanging down?

00:05:23 Levi
Okay, that's.

00:05:24 Doctor
It's not.

00:05:24 Doctor
Because we cannot leave it here.

00:05:26 Doctor
No, because then it would be in front of the urethra.

00:05:30 Doctor
And if there should be a problem with the urethra, we should not bend the clitoris.

00:05:37 Doctor
Bend the.

00:05:38 Doctor
We have the urethra around the clitoris.

00:05:41 Levi
Okay.

00:05:42 Doctor
And if the clitoris is in front of the urethra and there's a problem with the urethra, where to cut exactly.

00:05:48 Levi
Then I have a lot to think about.

00:05:50 Levi
Because then it might.

00:05:52 Levi
Doesn't sound like it'll help a lot to leave the clitoris in terms of sensitivity either.

00:05:57 Doctor
What I can tell is that almost none of our patients want to have the clitoris outside.

00:06:06 Levi
Right.

00:06:08 Doctor
But not because we tell them this will happen.

00:06:10 Doctor
This will happen.

00:06:11 Doctor
This is what they show up here with.

00:06:19 Doctor
I had some patients from our clinic and some from other clinics that.

00:06:26 Doctor
But this is quite some years ago that had the clitoris still outside and who wanted to have it buried then.

00:06:34 Levi
Right.

00:06:38 Doctor
There are not many patients who say that they want to have the clitoris removed out of the grave.

00:06:52 Levi
Like, take it out later? [Doctor:] Which is not possible.

00:06:54 Levi
Yeah, I understand.

00:06:56 Levi
But just theoretically, to just cover all bases, if I were to decide to leave it out and change my mind later, it's impossible to take it back in.

00:07:06 Doctor
Yeah, but not really back in.

00:07:09 Doctor
But what we would do then is it would be situated.

00:07:13 Doctor
Let's just say it would be situated here.

00:07:16 Doctor
What we would do then is to de epithelialize.

00:07:19 Doctor
So that means to take off the surface skin of the clitoris and then just close the skin over it.

00:07:30 Doctor
Okay.

00:07:31 Levi
So it wouldn't really go along the penis either.

00:07:34 Doctor
No, no, no.

00:07:35 Doctor
It's much too complicated and much too dangerous to cut open all that to get the clitoris somewhere there.

00:07:43 Levi
But if I bury it immediately, it will go along the phallus.

00:07:47 Doctor
Yeah.

00:07:48 Levi
Okay.

00:07:48 Levi
This is important information for me.

00:08:09 Doctor
[Draws on paper] If we look from the side.

00:08:11 Levi
Right.

00:08:12 Levi
Okay, so it's kind of.

00:08:13 Doctor
This is the urethra and the up.

00:08:18 Doctor
The downside.

00:08:18 Levi
Yeah, the downside.

00:08:20 Doctor
The downside of the clitoris looks into the urethra like this.

00:08:25 Doctor
And the clitoral gland is behind the anastomosis, the junction of the urethra from the prolonging that was done before to the phallus.

00:08:41 Doctor
And the clitoris gland itself is here.

00:08:45 Doctor
Maybe it makes a knick like this, or, you know, it's not positioned in an exact position.

00:08:52 Doctor
It's not possible.

00:08:53 Doctor
But it is there.

00:08:54 Levi
But it's.

00:08:55 Levi
Yeah, it makes sense when you're.

00:08:57 Levi
I think I just have to think a little bit about it.

00:09:01 Doctor
I'll show you that.

00:09:03 Doctor
This picture here, this is the downside of the clitoris.

00:09:07 Levi
Yeah.

00:09:07 Doctor
Because the klitpen is put like this.

00:09:12 Doctor
This is the clitoral gland, and this is the downside.

00:09:14 Doctor
And the rest of the clitoris stays here behind the anastomosis.

00:09:21 Doctor
And if you want to remove?

00:09:25 Doctor
Not remove.

00:09:25 Doctor
If you want to have the clitoris outside, then we need to dissect the urethra from the clitoris.

00:09:35 Doctor
And the clitoris then is put somewhere here.

00:09:37 Levi
Yeah.

00:09:38 Doctor
That suture in the skin.

00:09:40 Levi
It seems quite complicated to do that, actually.

00:09:43 Levi
And, yeah, there's a good chance I might not want it outside anyway, if that's the whole consequence of it.

00:09:53 Levi
But this is really good information for me, and I have to think a little bit about it.

00:09:59 Levi
But, yeah, let's see.

00:10:01 Levi
I have some more questions.

00:10:03 Levi
The type of scrotoplasty that you do, what is the name of it?

00:10:08 Levi
I've heard that there are several types.

00:10:11 Doctor
We call it vy.

00:10:14 Levi
Yeah, I've read about vy.

00:10:15 Levi
And there is another.

00:10:17 Levi
I don't really remember which one, but that is the one where you kind of leave things more or less where they are.

00:10:23 Levi
Is that it, or is it where the scrotum is?

00:10:28 Doctor
I mean, you know, that depends on the anatomy.

00:10:32 Doctor
What we try to do is to get as much tissue from down between the legs to the front.

00:10:41 Levi
Right.

00:10:42 Doctor
Sometimes it's just this way.

00:10:47 Doctor
Sometimes it's that we take flaps from down here and flip them up.

00:10:54 Doctor
It's this and this.

00:10:55 Doctor
But both results in.

00:10:57 Doctor
We make a cut like that, bring tissue up, and that cut gets a form like this.

00:11:05 Levi
Right.

00:11:05 Doctor
V y.

00:11:07 Levi
Okay.

00:11:07 Levi
That's where the word comes from.

00:11:09 Levi
Because I think I would be a little bit uncomfortable if it's too far between my legs.

00:11:16 Doctor
You don't want to have a colpectomy.

00:11:19 Levi
I don't know what that is.

00:11:20 Doctor
Closure of the vagina?

00:11:22 Levi
No.

00:11:22 Doctor
Okay, so then it's something completely different anyhow.

00:11:27 Levi
Okay.

00:11:30 Doctor
Then it's a modification of that vy.

00:11:36 Doctor
I do not have a picture of it.

00:11:38 Doctor
I just give you a picture of the V y.

00:11:41 Doctor
And sometimes if these flaps are very long, we put them in the middle.

00:11:46 Doctor
We cannot do this like that and put it together in the middle if there still is the vagina.

00:11:52 Doctor
Because the vagina is still there.

00:11:54 Levi
Of course.

00:11:55 Doctor
Okay.

00:11:55 Doctor
So the shape, it's just different.

00:12:02 Doctor
And it's not a standard procedure.

00:12:05 Doctor
I mean.

00:12:05 Doctor
Yeah, it's more or less the same.

00:12:08 Doctor
Same, but different.

00:12:10 Levi
Right.

00:12:11 Doctor
Okay.

00:12:11 Levi
You don't.

00:12:12 Doctor
I mean, you can imagine that we cannot do it exactly the same because there still is the vagina.

00:12:17 Levi
Yeah.

00:12:17 Levi
And I suppose it would have to, like, split in the middle there.

00:12:21 Doctor
Yeah.

00:12:21 Doctor
So we need two flats, definitely.

00:12:24 Doctor
Right and left from the vaginal entrance, and then flip them to the front as good as much as possible.

00:12:35 Levi
Okay.

00:12:36 Levi
You don't happen to have any pictures?

00:12:38 Doctor
No.

00:12:38 Levi
Okay.

00:12:39 Doctor
That's quite rare.

00:12:40 Levi
Yeah, I understand.

00:12:41 Levi
It's.

00:12:43 Levi
Yeah.

00:12:43 Levi
I'm a little particular with what I want.

00:12:46 Levi
Let's see.

00:12:49 Levi
So I think you said.

00:12:50 Doctor
But the procedure itself is.

00:12:54 Doctor
So if there is no vagina, the phallus is here.

00:13:02 Doctor
We make an incision like this and put all the tissue up.

00:13:07 Doctor
Try to put all the tissue upwards.

00:13:08 Doctor
If there's the vagina, we would make kind of the same incision.

00:13:14 Doctor
But then to here and to here, and put these flaps and flip them around.

00:13:20 Doctor
So on.

00:13:21 Doctor
So.

00:13:22 Doctor
Okay.

00:13:23 Doctor
And then suture that and that together.

00:13:28 Levi
Okay.

00:13:30 Levi
I suppose the vaginal entrance will be smaller.

00:13:34 Doctor
It will be smaller even after the forming of the klitpen.

00:13:42 Levi
Okay.

00:13:43 Levi
My question is, if it becomes too small, I heard some surgeons are willing to do surgery to open it up again later.

00:13:51 Doctor
If you need it to be open for sexual intercourse, then it must be opened.

00:14:01 Doctor
But there will be scarring, and it might be that it's not as wide and not as stretchable as it was before.

00:14:12 Doctor
And of course there will be scars.

00:14:14 Levi
Yeah, fine with that.

00:14:17 Levi
I've just been curious about that.

00:14:18 Levi
Like, is it possible?

00:14:19 Levi
Is it is?

00:14:21 Levi
Because if.

00:14:22 Levi
My thought was that if the hole becomes too small to use anyway, then I might as well remove it.

00:14:28 Levi
But I would like to keep it somewhat usable, if it's possible.

00:14:34 Doctor
It is.

00:14:34 Doctor
Generally.

00:14:35 Doctor
It is, but it's not to make it very easy.

00:14:39 Doctor
It's not the same as it is before.

00:14:40 Levi
Yeah.

00:14:42 Doctor
It is smaller, and if we widen it again, it is small, and there are scars around it.

00:14:49 Doctor
And if we widen it, that means we have to do some incisions and suture them, and then there will be scars again, and it might not be as flexible, as wide as it was before.

00:15:02 Levi
Okay, I understand.

00:15:06 Levi
I think you talked about this last time, but I don't remember.

00:15:12 Levi
With the staging, you do the klitpen first, and then you connect the urethra immediately after on the next stage.

00:15:24 Doctor
Yeah, we connect it, but we leave it open.

00:15:27 Doctor
You know, it's like a tube, a continuous tube, but with a longitudinal incision.

00:15:37 Levi
Yeah.

00:15:37 Levi
So there's a hole underneath that area.

00:15:42 Doctor
You pee out here so that the anastomosis can heal, and the urethra in the phallus can heal without being used every day.

00:15:59 Levi
Okay.

00:16:00 Doctor
If there's been.

00:16:00 Doctor
I mean, there are a lot of problems with the anastomosis here, or sometimes with the.

00:16:06 Doctor
With the urethra in the phallus.

00:16:10 Doctor
If there are problems.

00:16:12 Doctor
I mean, you do not like it anyway, but they do not affect your ability to pee.

00:16:19 Levi
Yeah, that makes a lot of sense.

00:16:21 Doctor
And if it should heal perfectly so that the next time you can put a probe inside and see it's wide enough, then we can just close it.

00:16:35 Doctor
Okay.

00:16:36 Doctor
But if there are problems, you do not like them, but they don't affect your micturition.

00:16:42 Levi
That sounds good.

00:16:45 Levi
I think I'm almost through with it.

00:16:47 Levi
I just have a question.

00:16:50 Levi
I've been doing some electrolysis, and I'm wondering how far up I should go.

00:16:54 Levi
You can kind of see the area where I've been removing hair.

00:16:59 Doctor
This area here, actually, is not important.

00:17:01 Doctor
That here.

00:17:06 Levi
Right.

00:17:07 Doctor
Show me the other arm.

00:17:10 Doctor
Well, to be honest, I don't think that you need much electrolysis at all.

00:17:15 Doctor
But it's not a wrong thing if you do it.

00:17:22 Doctor
This is not exactly what I'm drawing here.

00:17:25 Doctor
This is just to give you an impression.

00:17:35 Levi
Hmm.

00:17:36 Doctor
This is.

00:17:37 Doctor
That's a u.

00:17:40 Doctor
Yeah.

00:17:40 Levi
So this is the important part.

00:17:42 Doctor
That's the important part because that's the urethra.

00:17:45 Doctor
And you see, that's about 4 cm if it's exactly that way, or it's not that exact.

00:17:53 Doctor
But that part here, this is the skin that stays in place.

00:18:01 Doctor
That part here would be the surface of the phallus.

00:18:06 Doctor
So if there should be hair, you can remove them afterwards on your own with, I don't know, shaving or silk appeal by brown or whatever with some.

00:18:19 Doctor
Something.

00:18:20 Doctor
But you cannot do that here.

00:18:21 Doctor
So this is more important.

00:18:23 Levi
Okay, so I'll focus on this area.

00:18:24 Doctor
Yeah.

00:18:25 Doctor
And of course not exactly on this area, but a bit.

00:18:29 Levi
Yeah.

00:18:29 Levi
I'm thinking maybe I'll do a little bit further, just in case.

00:18:32 Levi
But I was wondering, should I have some more removed?

00:18:36 Levi
I mean, if it happens that you need more skin, does that ever happen?

00:18:41 Doctor
No, we do not go further than those 4 cm here.

00:18:46 Levi
Okay.

00:18:47 Doctor
If we need more skin, we take it from the skin transplant like this.

00:18:58 Levi
Okay.

00:18:58 Levi
The skin transplant being the skin you.

00:19:00 Doctor
Fetch from the skin that we use to cover that.

00:19:03 Levi
Yeah.

00:19:05 Doctor
Part of this was...

00:19:10 Doctor
Look at this.

00:19:12 Doctor
Anyhow, we use a skin transplant because we sometimes we.

00:19:18 Doctor
Maybe it would be possible in your case, because it's very soft tissue, that we could close the phallus directly, but then it's a bit tight and of course the circumference is smaller.

00:19:32 Doctor
So the consequence is not that we enlarge the flap, because an enlargement of the flap also means the flap, more flap tissue must be, there must be blood flow.

00:19:48 Doctor
But what is missing is covered by the skin that we take from the skin plant that we use anyhow to cover that here.

00:19:56 Doctor
Okay.

00:19:56 Doctor
And this is on the downside of the fellow, so you do not see it in everyday life.

00:20:01 Levi
Okay.

00:20:02 Levi
But anyway, I should do like a couple of centimeters.

00:20:06 Doctor
Yeah, yeah, yeah, yeah, yeah.

00:20:07 Doctor
I mean, it's better to do more.

00:20:08 Levi
Than too little, but then I won't focus too much on this.

00:20:12 Doctor
No, that's the important part.

00:20:15 Levi
I understand.

00:20:17 Levi
So, yeah, this is like a fixed size.

00:20:20 Doctor
Not really fixed.

00:20:21 Levi
Okay.

00:20:23 Doctor
Smaller is always possible.

00:20:25 Doctor
Larger is not always possible.

00:20:27 Levi
Okay.

00:20:28 Levi
But if I said that I would prefer that you took an extra centimeter if you're able to.

00:20:34 Levi
Is that something you take into consideration?

00:20:36 Doctor
Yes, but it's the thing, the most important thing is the length of the vessels here.

00:20:43 Levi
Okay.

00:20:44 Doctor
Because we could make the nicest and the longest and the best phallus ever.

00:20:49 Doctor
But if those vessels are too short, we do not have good possibilities to connect them with the blood vessels down there.

00:20:57 Doctor
And so there is a problem with the blood flow and then it's all for nothing.

00:21:03 Levi
Yeah, I wouldn't take any chances there.

00:21:06 Doctor
Yeah, yeah, yeah.

00:21:07 Levi
At the same time, you know, who doesn't prefer having a bigger size if you're able to?

00:21:12 Levi
So it's just.

00:21:14 Levi
Yeah, I think that is all the questions I had, actually.

00:21:18 Doctor
Okay.

00:21:19 Levi
I've gone through the list at least, so I'm going to get you asked for a document saying exactly which.

00:21:28 Doctor
The one thing from the.

00:21:29 Doctor
I don't know who.

00:21:30 Doctor
I guess it was a hormone specialist from the.

00:21:35 Doctor
From the Rijks hospital in.

00:21:36 Doctor
In Oslo.

00:21:38 Levi
You need a letter from the hormone.

00:21:39 Doctor
No, not.

00:21:40 Doctor
But the one you sent me.

00:21:42 Levi
Oh, no, that's from the chief doctor at the hospital.

00:21:45 Doctor
Really?

00:21:45 Levi
Yes.

00:21:45 Doctor
Okay.

00:21:46 Doctor
You know, the thing is.

00:21:47 Doctor
The thing is that just.

00:21:48 Doctor
He was saying a lot about the hormonal treatment or what is to be done if the.

00:21:53 Doctor
If the hemoglobin is too high or whatever, but.

00:21:56 Doctor
And that you fit the.

00:22:01 Doctor
The conditions for gender reassignment surgery.

00:22:07 Doctor
I would need to know a bit more what these.

00:22:10 Doctor
You know, I don't know.

00:22:10 Doctor
Does he mean the w path conditions or what kind of conditions is meant by that?

00:22:19 Levi
I will ask him for the specific document that he is referring to because he referred to some sort of standard.

00:22:25 Doctor
Okay.

00:22:26 Levi
I will ask exactly for that study.

00:22:28 Doctor
I wrote you that letter in German, didn't I?

00:22:31 Levi
I think you did, but I used Google translate, so that's fine.

00:22:34 Doctor
But at the end of that letter, where do I have it?

00:22:40 Doctor
At the end of the letter, there is a box saying at least.

00:22:46 Doctor
I mean, it's the German guideline, but it's quite close to the wpath guidelines.

00:22:53 Doctor
It says what needs to.

00:22:54 Doctor
What the statement needs to say that we need to know the diagnosis.

00:22:59 Doctor
We need to know that you're informed.

00:23:02 Doctor
I know that you're informed, so that's fine.

00:23:04 Doctor
And we need the recommendation, the referral for the specific treatment.

00:23:12 Levi
Okay, so.

00:23:15 Doctor
Levi is transgender, and he's been going through psychotherapy, not treatment, but, you know.

00:23:28 Doctor
And the only way to cope the problems he's having with the gender dysphoria is to do gender reassignment surgery.

00:23:36 Doctor
Something like that.

00:23:38 Doctor
That's it. The box says...

00:23:39 Levi
I will go through the letter and I'll write a letter and get the specifics.

00:23:46 Levi
Yeah, yeah, yeah.

00:23:49 Doctor
It's.

00:23:49 Doctor
We know it's.

00:23:50 Doctor
You know, it's not five pages.

00:23:51 Doctor
It's a bit more than two lines.

00:23:53 Levi
Yeah, yeah, I understand.

00:23:55 Levi
But I will get that to you and you'll get it by email.

00:23:58 Doctor
All right.

00:24:01 Levi
Thank you so much for answering.

00:24:04 Doctor
No worries.

00:24:05 Levi
And you'll hear from me soon.

00:24:07 Doctor
Okay, bye bye.

00:24:08 Doctor
Bye bye.


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