Male to Female (MTF) Surgical FAQ and Checklist – Part 3

This is a male-to-female (MTF) surgical FAQ by Dr. Harold Reed. The piece is the third of a four-part series on the procedure.

17. Even though I am overweight, may I still schedule surgery?

While individual consideration is given in every case, we are disinclined to operate on obese people in an outpatient - 24 hour hold setting, as they pose a greater risk for complications. For your information, smoking and obesity are the two most preventable causes of early death in the United States. If you would call the office and give us your height and weight, we'll tell you where you stand on the charts. You may wish to review the "ideal weight charts" for women and men

Clearly the first recourse for obese patients is weight reduction. For those patients who have not responded well to dieting, please consider a hospital environment for the benefits of supportive nursing care and respiratory therapy.

Occasionally we had experienced some misrepresentation when arriving patients are weighed here in our office. Please do not tell me you gained weight unexpectedly because you were told to stop smoking, or that you are 5' 2" and weigh 180 pounds but "you can't see it," or have big bones, or had silicone injections or breast implants, or don't have a scale at home, or do not weigh yourself regularly, or "my scale must be broken," or "your scale is broken," etc. There is no shortage of scales in our medical community.

There's not a line we haven't heard. After spending your hard earned money to travel here perhaps with a friend or loved one, arrange to take a leave of absence from your job, making a reservation at the nearby motel, you will find your case has been cancelled only to be rescheduled when you are at the suggested weight.

There is an acceptable range and yes we can cut you some slack if you are a few pounds over, that's not 10 or 20 pounds over.

Overweight people are more difficult to manage pulmonary wise, have heavier legs with the threat of neural or circulatory compression, and are technically more difficult to operate on. Beyond that you are giving their poor heart an extra work assignment to pump blood into tissues which are not needed for appearance or function.

Most importantly, do not take Ephedra (or like drugs). It's a killer. You will have a tachycardia (fast heart rate) on the operating room table and your case will be cancelled. 

18. Even though I am thin may I still schedule surgery?   

How thin is thin would be the next question.   Your BMI, a relation of weight to height will give us some idea.  Please see to obtain your BMI.  Here is a BMI table for reference.
Underweight = 18.5 or less
Normal weight = 18.5-24.9
Overweight = 25-29.9
Obesity = 30 or greater
Vaginoplasty is a more stressful procedure than a breast implant or facial surgery and the incision lines are a lot longer.  Your torso weight, which could be 80 pounds or more, on your perineal incisions contributes to wound separation.   For this reason I propose for optimal wound healing, your BMI be 22 or higher.  If your BMI is below 22, please consider a medical evaluation, and consume more calories preoperatively.   Many patients will lose 10 pounds after surgery for a while, and which places them in a underweight category.

19. Alternate centers?

During Thanksgiving week 2003, I visited with Dr. Sanguan Kunaporn of Phuket, Thailand who operates at the Phuket International Hospital. Dr. Kunaporn is a very versatile plastic surgeon who has trained in the United States. His fees are comparable to ours and his technique and facility are first class. The nurses are exceedingly attentive, the rooms are spotless, the food is more hotel quality than hospital fare, the operating room environment is very quiet and well organized, and every staff member knows exactly what to do, blood loss is minimal. More than that I can assure you he is completely focused on what he is doing and fusses over every stitch. The eye contact with patients is very good. In all, a very high class ethical operation.

20. Will I need a medical grade vaginal dilator or dildo post operatively?

Yes, you certainly will.  We will provide the standard set of medical grade stents for 350, but recommend that you purchase an additional smaller set for 150 as well in that many patients are too tender to use the standard size set one week after surgery..  You may be able to purchase stents less expensively, but the vendor will not be there for you if your misapply and traumatize yourself.  Please avoid stent with grooves as on withdrawal they tend to pull the vagina outwards (vaginal prolapse).  Avoid nesting hollow stent sets with one interchangeable handle, as the narrowest sizes are way too short.

21. Are any of your patients amenable to speaking with me? 

As you may know the new HIPAA laws are very strict about patient confidentiality. However a recent patient of ours has chronicled her personal experiences on the web at
I am given to understand that upon completion of her second stage labiaplasty, she'll release some photos.  Best to let her do the talking.

22. Any special pre-operative instructions? 

A CBC should be performed 2 months before your scheduled procedure. If your blood count is low normal or below normal values, a hematology consult may be needed.
Better to learn of this well in advance.

Within 10 days before surgery, all patients are required to have these blood tests: a CBC (again), PT, PTT, and platelet count. Our lab fee is $100, but you could have this done in your home town perhaps more reasonably.

All patients require a letter of medical clearance with reference to an EKG and chest  X-ray to be obtained within 7 to 10 days  before your scheduled procedure.  If you have cardiovascular risk factors or are over 40, you may also require a thallium stress EKG.

REGARDLESS if you are having a first stage vaginoplasty, a touch up or revision (2nd stage vaginoplasty), or even an orchiectomy, STOP  estrogens a good month before surgery, as this may predispose to thromboses or emboli (unwanted clotting including the potential for fatal pulmonary emboli, coronary events, and/or stroke) .  If you do not do this, your case may very well be cancelled.  You may resume 10 days after surgery.

Also stop spironolactone within 2 weeks of your procedure as this medicine may interfere with the response of certain drugs administered during anesthesia called vasopressors.

No aspirin or aspirin products, no anti-inflammatory drugs such as Motrin, Advil, Alleve, or Cox 2 inhibitors such as Celebrex or Vioxx for a week before surgery. No Vitamin E, fish oil, or excessive alcohol or spices for a week before surgery as this may promote bruising.

Bruising can be reduced (many believe) with Bromelain 500 mg 1 twice a day, Arnica montana (Boiron brand) dose 30C (take 4 small tablets sublingually, 4 times a day), vitamin C 500 mg (3 times a day) starting 1 week before surgery. Do take these medications unless there are specific reasons why you choose not to and let's discuss it beforehand.

If for any reason, despite tight scheduling arrangements and eager anticipation of being converted, you have contracted an illness such as a flu like syndrome with coughing, sore throat, fever, or diarrhea, please reschedule allowing a good two weeks for recovery. These things happen and we are very sympathetic. Surely we do not want any patient with a very recent cold to have general anesthesia. If you have gained weight, please advise as we may have to postpone surgery.

If you are a smoker, you must stop completely for 2 months before surgery and please never smoke again. Smoking causes vaso-spasm, impairs wound healing, produces excessive scarring, tissue necrosis, irritates and inflames pulmonary membranes and enhances anesthetic risk.

This goes also for any products containing nicotine or nicotine like agents including nicorette gum, nicotine patches, Nicotrol inhalers, and second hand smoke. Again not for 8 weeks before and not for 8 weeks afterwards. Hopefully never again.

If you have a history of inflammatory bowel disease, such as Crohn's or regional enteritis, please get clearance from your GI doctor, as rectal inflammation can be an inciting factor for the post-operative complication: rectal-vaginal fistula.

A medical study relating to wound healing and diet classified patients into 3 groups, pure vegetarians, those that also ate chicken and fish, and those that ate all common foods including red meats

Those who eat red meats heal the best and quite honestly probably have the best iron reserves to assist with making more red blood cells to replace a loss.

Personally, I do not believe irregular bowel movements and constipation should ever be accepted as a way of life. Such patients are prone to ano-rectal disease including diverticulosis (-itis), hemorrhoids, fissures and fistulas.

We use the technique of pull up sutures to prevent prolapse. These sutures are removed on the 7th post-operative day. Usually what you see at the end of the operation is pretty much what you get, but not always.

Obtain one pair of anti-embolism thigh high stockings. T.E.D. (by Futuro) or Jobst are common brand names.  Yes, do try these on before you come here to be sure they fit comfortably. If you wash or dry them in a hot cycle, they may never fit properly again. So best not to wash them at all until after surgery.

As a courtesy to the hotel, please obtain and bring with you a bundle of "chucks" or disposable superabsorbent pads with plastic liner on underside (typically 24 by 36 inches) to conserve hotel laundry and bedding.

Please be sure both left and right index finger nails are not covered with nail polish or artificial fingernails. We need to see a pink nail bed for an accurate pulse oxymetry (oxygen level monitoring during anesthesia).

A bowel prep should be started 24 hours before surgery which will include clear liquids only, a half a bottle of citrate of magnesia at 8 AM and the other half at 4 PM, a Fleet's enema at 10 AM, 3 PM and on the morning of surgery. Also on the day before surgery, neomycin sulfate 1 gram and Flagyl 1 gram, to be taken by mouth at 1 PM, 2 PM and 11 PM.

Please keep up with a good fluid intake the day before surgery.

Nothing by mouth after midnight unless otherwise instructed.  Do not shave yourself as we will do that for you.

Please remove all piercings and body jewelry (especially tongue, belly, lip, etc.) before anesthesia along with jewelry and store them ideally at your hotel.

Ring pillows should not be of the inflatable variety as they may deflate unexpectedly.

This is a male-to-female (MTF) surgical FAQ by Dr. Harold Reed. The piece is the third of a four-part series on the procedure.

See also: Male to Female (MTF) Surgical FAQ and Checklist – Part 1
See also: Male to Female (MTF) Surgical FAQ and Checklist – Part 2
See also: Male to Female (MTF) Surgical FAQ and Checklist – Part 4

This is a sponsored post. 

If you’re looking to sponsor a post please contact us at info [at]


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