II Gender Affirming or Affirmation Surgery (GAS)

choi

(2) Female to Male:

Jamie Lauren Keiles, Private Parts. Phalloplasty -- the surgery to make a penis -- has grown more popular among trans men.But with a steep rate of complications, it remains a controversial procedure. New York Times Magazine, May 15, 2022, at page 37.  
https://www.nytimes.com/2022/05/10/magazine/phalloplasty.html
https://www.banoyi.com/how-ben-got-his-penis-307574.html

Note:
(a) "[possibly in her teens] Though Ben did know that he liked girls, he did not feel like a lesbian at all. * * * [at college: NYU] He had long debates over terms: What was the difference between a butch lesbian and a transgender man? * * * Though he had read about 'bottom surgery' online, the final outcomes did not seem good enough for him to justify the risks. People were comparing the results to soda cans, he recalls. 'They were saying they weren’t functional. You couldn't pee out of them. You couldn't feel anything.' * * *  [in a NYC bar] Management had removed the bathroom stalls to keep people from doing cocaine. An undefended toilet [no door or compartmentation (not even wall)] next to a urinal is not an ideal place for a trans man to take a leak, but Ben was confident — and had to go. He walked past a guy using the urinal and quickly unzipped to sit on the toilet. The man kept his eyes to himself (the men's room code), but as he left, he told the people waiting: 'It's going to be a while. That guy just sat down.'  This was hardly an incitement to anti-trans harassment — he just thought Ben was taking a dump. * * * Having a penis would help him feel safe, even if he still had to sit down in a stall [phalloplasty without urethra inside the shaft of constructed phallus is called no urethral lengthening, which makes the work (of phalloplasty) a bit easier; different patients have different goals]. * * * That night, drunk at home, he ran a search for 'FTM [female-to-male bottom surgery' and spent all night reading up on phalloplasty. The following week, he submitted a request for a consultation with Dr Rachel Bluebond-Langner at NYU. * * * The penis, as an organ, is idiosyncratic, assigned to a seemingly random set of duties that you might not group together if designing it from scratch 0from the evolutionary point of view, it (the various functions) makes sense. I note the writer is a woman] * * * Though phalloplasty cannot yet produce a penis identical to the one most men are born with, it can provide for many of the classic penile pastimes: standing urination, penetrative sex, orgasm (without ejaculation), changing in a locker room. * * * Ben prepared for his consult with Bluebond-Langner and Lee Zhao, a reconstructive urologist and the co-director of NYU Langone's transgender-surgery program,."
(i) butch
https://www.etymonline.com/word/butch
(ii) "[T]he difference between a butch lesbian and a transgender man" is not easy to tell, as one may be a lesbian (who life women rather than men) but refuses to admit that fact, so she fantasizes herself bring a man. There is no harm as long as surgery, which is one-way, is not contemplated.  
(iii) Though he had read about 'bottom surgery' online, the final outcomes did not seem good enough for him to justify the risks. People were comparing the results to soda cans, he recalls. 'They were saying they weren't functional. You couldn't pee out of them. You couldn't feel anything.'

I do not know exactly what soda can is referred to. Certainly the constructed phallus will be "think" (as the NYT Magazine later in the article describes, which means huge diameter, like an elephant's trunk (which is not body); post-operative swelling will make the neophallus even bigger. Certainly the neophallus can not shrink and enlarge, like a normal one. But it does have sensation: that of a normal skin, because it is made of skin.
(iv) "That guy just sat down. * * * he just thought Ben was taking a dump"
(A) To me as a heterosexual man, that means nothing: Ben could be defecating. But some men can tell from body language that another man might not be straight.  
(B) dump (n): "often vulgar : an act of defecation —usually used with take"
https://www.merriam-webster.com/dictionary/dump
(v) Rachel Bluebond-Langner, MD. Laura and Isaac Perlmutter Associate Professor, Department of Plastic Surgery
https://nyulangone.org/doctors/1902867393/rachel-bluebond-langner
(Residency, John Hopkins University School of Medicine, Plastic Surgery, 2011; MD from Johns Hopkins University, 2003)
(vi) Lee C Zhao, MD. Associate Professor, Department of Urology
https://nyulangone.org/doctors/1679729297/lee-c-zhao
("Prior to becoming a physician, I attended graduate school for biomedical engineering [and received MS as a result, but I can not find where] and volunteered in the Peace Corps * * * Fellowship, UT Southwestern Medical Center, Reconstructive Surgery, 2013
Residency, McGaw Medical Center of Northwestern University, Urology, 2012
MD from Northwestern University, 2006")
(vii) NYU Langone Health
https://en.wikipedia.org/wiki/NYU_Langone_Health   
("NYU Langone comprises NYU Grossman School of Medicine and several inpatient facilities * * * in 2008 after a $200 million gift from Kenneth and Elaine Langone.[5] Kenneth Langone is the chairman of the board of trustees")

The map shows medical campus is separate from NYU main campus at Washington Square.
(viii) "Though phalloplasty cannot yet produce a penis identical to the one most men are born with, it can provide for many of the classic penile pastimes: standing urination, penetrative sex, orgasm (without ejaculation) * * * "

At first, this is what I thought: How can phalloplasty induce orgasm? Or excitement? From biological perspective, it (neophallus, with a tube of tissue (of subcutaneous fat) and ordinary skin, can not!  However, let's return to Part I Male to Female, where Note (c)(ii) was
Doo FX et al, Gender Affirmation Surgery: A Primer on Imaging Correlates for the Radiologist. American Journal of Radiology, 213: 1194 (2019).
https://www.ajronline.org/doi/pdfplus/10.2214/AJR.19.21686
, where Figure 2 says in caption that clitorius is retained and "buried at the base of [neo] phallus."


(b) "In the United States, there are two common types of phalloplasty: radial forearm flap (or RFF, which uses the forearm as a skin-flap donor site) and anterolateral thigh (or ALT, which uses the thigh). These flaps form the shaft and can be combined with various other procedures in pursuit of four major post-op priorities: standing urination, aesthetics, erectile function and sensation. * * * As Ben prepared for his consult with Bluebond-Langner and Lee Zhao, a reconstructive urologist and the co-director of N.Y.U. Langone’s transgender-surgery program, he researched the differences between ALT and RFF The thigh’s skin is longer and tends to have more fat, which can add girth to the penis, for better or for worse. The forearm’s skin, by contrast, is shorter and leaner. The scar it leaves behind is more visible. Both procedures have similar complication rates. Ben’s primary goal was standing urination. He decided his next goals were penetrative sex and aesthetics, in part because he would be in a rural dating pool and would probably be the first trans guy most women had been with. At 4-foot-10 and 97 pounds [Ben was a woman after all], he felt he had certain disadvantages. “Women don’t like short men,” he said. 'I kind of had to give myself all the edge up on the competition I could get.' Because he was so lean, ALT seemed like a fit. 'If I got RFF,' he said, 'I would absolutely have a very thin penis [I am not a woman, but I do not believe women's vaginas can tell the difference of a penis during penetration about diameter; O am completely ignorant whether women can sense difference in length; And I doubt a penis more than 4 or 5 inches can go all the way in to the hilt, the rest of the penis shaft must be left behind. On the other hand, Ben was a woman, so she must know something].'  Bluebond-Langner and Zhao agreed that ALT was the right choice, especially because Ben's penis needed to be thick enough to support urethral lengthening."
(i) Johns Hopkins University has a web page for three kinds of phalloplasty:
radial forearm free flap (RFFF, which is John Hopkins acronym),
anterolateral thigh flap (ALT), and  
musculocutaneous latissimus dorsi flap (MLD).

RFF is the most common and achieves the best result.

In case of phalloplasty with neourethra in one operation, tube-in-tube method is used.
(A) Brazio et al (from Stanford U), EMJ Editor's Pick: Penile Reconstruction: Current Thoughts, Techniques, and Outcomes. EMJ Urol (Urology - European Medical Journal), 8: 12 (May, 2020; review)
https://emj.emg-health.com/wp-co ... es-and-Outcomes.pdf

In Figure 1(A), RA and RV are radial artery (red) and radial vein (blue), respectively. Two nerves are colored yellow. Figure 1(B) show tube-in-tube, coronoplasty (also known as glansplasty: the cone at the end of the shaft). Figure shows ALT; instantly one will why it is so named (the location of the flap is in the anterolateral aspect of the thigh).
(B) Pelvic and Urogenital Reconstruction. Plastic Surgery Key, undated
https://plasticsurgerykey.com/pe ... tal-reconstruction/

View Figure 19.5 and the 1-paragraph text immediately before the figure.
Figure 19.5: top lift panel show a flap with (surface of) skin (pinkish) and subcutaneous fact (whose skin is cut away; yellow). The top right panel us the right side of the same panel. Yet the bottom panel is wrong: wjem the surgeon rolls the left-most part of the flap, the skin should face inward becoming the inside the neourethra.
(C) Yao A et al, Total Penile Reconstruction: A Systemic Review. JPRAS (Journal of Plastic, Reconstructive & Aesthetic Surgery, formerly the British Journal of Plastic Surgery), 71: 788 (2018).
https://www.jprasurg.com/article/S1748-6815(18)30064-0/fulltext

This paper is locked behind paywall. The fire at issue is attachment 1 , where "Inter-paddle segment" is the subcutaneous tissue we saw in the skip flap in Figure 19.5.
(D) Hilary Wilson, Female to Male Phalloplasty: Tube-in-Tube Forearm vs Thigh Flap . Shannon Associates
is also behind paywall, whose figure is attachment 2.
(E) Figure 2 in Hontscharuk R et al, Strategies for Innervation of the Neophallus. Plastic and Aesthetic Research (Plast Aesthet Res or pAR for short), 7: 65 (2020)
https://oaepublishstorage.blob.c ... baebbecc9e/3770.pdf
https://parjournal.net/article/view/3770
(the first link was odf and the second, html -- the only difference is the latter does not have volume and page numbers) demonstrates the real thing. Take note of this flap being attached at the left to the forearm, which is necessary to preserve blood supply and innervation.


(c) "Some risks [with phalloplasty] are common and ultimately manageable: dribbling while urinating * * * Rachel Bluebond-Langner, 44, has the open affect * * * When Bluebond-Langner started her rounds * * * a transgender journalist could be forgiven for feeling more than just a little cynical. Trans people in America are in a complex bind with the medical establishment: On one hand, there's the call to expand and improve care that has historically been denied; on the other, most of us are not blind to the fact that our bodies make good business in a for-profit system. 'We're salaried [still more patients probably lead to salary hike],' Bluebond-Langner said, by way of explaining that she doesn't get more money for more patients. 'Though they do incentivize us a little bit. They'll give us more resources.' * * * Inside [Bluebond-Langner's private office om NYU hospital], above a consultation table, hung an autographed poster of the 'Pose' actress Dominique Jackson. * * * One patient, for instance, might choose to pursue standing urination but have no practical use for an erectile implant. Another might experience dysphoria as mainly visual but still enjoy vaginal receptive intercourse; phalloplasty without vaginectomy could meet this need with fewer procedures. 'You can do glansplasty, no glansplasty. Scrotoplasty, no scrotoplasty. You can really do a whole mix-and-match thing to meet your goals,' Bluebond-Langner said. * * * The FDA-approved erectile implants are designed for the bodies of cisgender men. The one trans-specific implant is not approved in the United States

(i) Men, women, boys and girls pee with a stream. The clause "dribbling while urinating" signifies partial blockage in neourethra. The noun dribble means a trickle (drip means drop by drop -- even slower). Here is a hoto of dribble,
https://www.dreamstime.com/royal ... dribble-image162256
(ii) affect (n): "[German Affekt, borrowed from Latin affectus] psychology  a set of observable manifestations of an experienced emotion : the facial expressions, gestures, postures, vocal intonations, etc., that typically accompany an emotion
Evidence from several clinical groups indicates that reduced accuracy in decoding facial affect is associated with impaired social competence.
<Other victims of schizophrenia sometimes lapse into flat affect, a zombielike state of apparent apathy.  — David G Myers" (brackets and italics original).
https://www.merriam-webster.com/dictionary/affect
, whose accent is in the first syllable.
(A) German noun masculine Affekt -- German noun always has the first letter capitalized -- means affect as an English noun.
(B) Latin-English dictionary:   
* affectus
(n)
(perfect passive participle of verb afficere influence, have an effect on)
https://en.wiktionary.org/wiki/affectus
(C) The Oxford online dictionary (Lexico.com) says its etymology this way: "late 18th century (in philosophy, in the sense 'an emotional, unreflective response'): coined in German from Latin affectus disposition from afficere to influence (see [English verb] affect)."
(D) The key to the noun affect in psychology is that affect is what one observes and deduces what another person experiences in terms of the latter's emotions.
(iii) Tips for Participating in Rounds. Children's Hospital of Philadelphia (CHOP), undated
https://www.chop.edu/health-resources/tips-participating-rounds
("As a vital part of healthcare partnerships, patients and families are encouraged to participate in the discussion about their care when the healthcare team is making clinical rounds of the inpatient units. Rounds are when the medical team visits each inpatient as a group to review the patient’s status and care plan" -- both both patients and members of the medical team should ask questions)

My guess is that the round comes from these following definitions, as a medical team within a department in a hospital has certain beds assigned to that team, which are usually but not necessarily dispersed.
round (n):
"5 a: a circling or circuitous path or course
* * *
6 a: a route or circuit habitually covered (as by a security guard or police officer)
b: a series of similar or customary calls or stops   <an endless round of fundraisers, Congressional testimony>
   especially : a series of regularly scheduled professional calls on hospital patients made by a doctor or nurse —usually used in plural  <… if laboratory test results are not available to physicians when they make their routine morning rounds, they may have to delay patient management, repeat their rounds at a later time>"
(iv) "a transgender journalist * * * most of us are not blind to the fact that our bodies make good business in a for-profit system"
(A) The writer, Ms Jamie Lauren Keiles, has her own website (which does not display a photo), which says, "I'm a contributing writer at The New York Times Magazine. I am currently working on The Third Person, a book about nonbinary gender in America, for Farrar, Straus and Giroux."

I am impressed by her clinical (meaning detached) observance and independence from the interviewees.
(B) Her photo (found in images.google.com) looks like a woman, but the quotation suggests she is a trans woman (born male).
(v) Dominique Jackson (model)
https://en.wikipedia.org/wiki/Dominique_Jackson_(model)   
(1975- ; "Being accepted as transgender by her family and community in Tobago [Trinidad and Tobago is where she was born as male and frew up[  was never a possibility, and she was regularly reprimanded for displaying her natural feminine characteristics"
(vi) "One patient, for instance, might choose to pursue standing urination but have no practical use for an erectile implant. Another might experience dysphoria as mainly visual but still enjoy vaginal receptive intercourse"

Both mean to refer to transmen (born female). Judging from the context, I would say "Another might experience dysphoria as mainly visual" means the person (bor female) is unhappy with lack of penis, scrotum etc, and desires a nonfunctional installment(s).


(d) "The main specialties of gender-affirming care — endocrinology and plastic surgery — were founded in the early 1900s, not as a means of transmogrifying gender but rather as tools for reifying it. Eugen Steinach [1861 – 1944; Austrian] * * * The basic techniques of plastic surgery stretch back more than two millenniums, but the discipline matured in the course of World War I as a means of restoring the bodies of blast victims so that they might better rejoin the world as men and husbands. Harold Gillies, an early British plastic surgeon, popularized the tubed pedicle, a general technique for moving tissue across the body by shaping a flap of skin into a tube and inching it toward the site of injury through periodic cutting and reattachment [to move the pedicle from its riginal location to a distant place in the same person].* * * In 1939, the British Ministry of Health, foreseeing the mass disfigurement of World War II, called on Gillies to found Rooksdown House, a plastic-surgery hospital. It was there that he would meet Lawrence Michael Dillon, the man on whom he eventually performed the world's first known gender-affirming phalloplasty.  Dillon was born in 1915 and raised as a girl by two morose aunts on a shabby estate near Dover. At St Anne's, a women's college at Oxford, he spent most of his time rowing crew and wore his hair in the Eton crop — a short and slicked-down hairstyle, popular with lesbians on campus. Though Dillon liked girls, he did not think of himself as a lesbian; he dreamed of being taken to the blacksmith and somehow melted down into a man. Around the outbreak of World War II, he went to see a doctor who specialized in sex, who prescribed him tablets of testosterone. He had a mastectomy a few years later. This surgeon suggested he go see Gillies about a penis. * * * In May 2020, Bluebond-Langner stitched up the channel [to create neourethra], connecting his existing urethra to his new one. At age 28, Ben was potty-trained again, teaching himself to pee standing up with a children's urinal suctioned to the wall of his shower. * * * He first used a public urinal a few months later, on crab-leg night [when legs of Alaska king crabs are served, buffet-style] at a restaurant in his hometown. * * * Through various 'American Pie'-style experiments involving multiple condoms for stability and a sex toy from an online store called Cherry Pie, he already knew he could feel a few sensations — hot, cold, tactile, erogenous. The implant he wanted, the Coloplast Titan pump, would allow him to elicit an erection on demand by a squeezing a device inside his scrotal sack. Ben hoped to get the implant — and a matching silicon testicle — sometime in early 2022, but before that he wanted to address two complications. First, his urine stream had grown weak, and he worried he might have a urethral stricture. Second, his penis was still very thick — far too thick to put his hand around.  In March 2021, Ben took an overnight bus to New York to consult with Bluebond-Langner and Zhao about these post-surgical concerns. I met him at the hospital at 8 am * * * Inside the examination room, a nurse instructed Ben to get undressed from the waist down. I offered to excuse myself, but Ben said it was fine to stay. He dropped his pants and pulled on a gown. His penis was a respectable length by any measure. It was thicker and paler than any I had personally seen, but it otherwise looked unremarkably handsome. * * * I spoke to Ben on and off over those months. Though he did not yet have his erectile implant, he was starting to feel optimistic about his future sex life. Through various 'American Pie'-style experiments involving multiple condoms for stability and a sex toy from an online store called Cherry Pie, he already knew he could feel a few sensations — hot, cold, tactile, erogenous. The implant he wanted, the Coloplast Titan pump, would allow him to elicit an erection on demand by a squeezing a device inside his scrotal sack. Ben hoped to get the implant — and a matching silicon testicle — sometime in early 2022, but before that he wanted to address two complications. First, his urine stream had grown weak, and he worried he might have a urethral stricture. Second, his penis was still very thick — far too thick to put his hand around.  In March 2021, Ben took an overnight bus to New York to consult with Bluebond-Langner and Zhao about these post-surgical concerns. I met him at the hospital at 8 am * * * Ben went in for his 'debulking' procedure that summer. His penis didn't turn out as slender as he wanted, but finally he could grasp it in one hand. * * * 'Now let's try to deflate it,” Zhao said. Ben squeezed the pump inside his scrotum with his right hand. With the left [hand], he began to compress his shaft like an accordion, pushing the saline back into the reservoir. * * * Ben took out his phone and put on King Missile's college-radio standard, 'Detachable Penis,' which he said reminded him of his life before phalloplasty."
(i) English dictionary:
* transmogrify  (v; Did You Know?)
https://www.merriam-webster.com/dictionary/transmogrify
* reify (n; Did You Know?  Latin noun feminine res thing)
https://www.merriam-webster.com/dictionary/reify
is modeled after deify (first found in 14th century).
(ii)
(A) The Birth of Plastic Surgery. National Army Museum (UK), undated.
https://www.nam.ac.uk/explore/birth-plastic-surgery

consecutive paragraphs:

"The tubed pedicle [sectional heading]

"Gillies puzzled over how to ensure that larger skin grafts could be accepted over the site of the injury, until he operated on Willie Vicarage. Willie had been badly burned in a fire during the Battle of Jutland (1916). His face was left as a fixed scarred mask and he couldn't shut his eyes or mouth.

"Gillies proposed to raise a 'Masonic Collar Flap' of skin from Willie's chest to repair the lower part of his face. During the operation, Gillies noticed that the edges of the pedicle flaps curled in on themselves under tension. He decided to sew them into a tube and found that the risk of infection was reduced and the blood supply was much better.

"Once the tubed pedicle had become firmly attached near the site of the injury, it could be cut away from the donor site, opened and spread out to graft a much wider area if required.

"This pioneering work by Gillies and his team marked a huge advance in reconstructing the faces of severely injured men. It also laid the foundations of modern plastic surgery.

• Search images.google.com with (masonic collar).
(B) Rooksdown
https://en.wikipedia.org/wiki/Rooksdown
("is shown as Rooks Down in the Ogilby strip maps of 1675. It is also the name of the old Roman road that passes through the Parish, and of the now demolished Rooksdown Hospital, originally Rooksdown House (the Private annexe of Park Prewett Hospital)"_
• down (n; from Old English [noun feminine] dūn [hill]): "an undulating usually treeless upland with sparse soil —usually used in plural   <sheep grazing on the grassy downs>"
https://www.merriam-webster.com/dictionary/down
In fact, down as adv, adj, preposition, verb and down is derived from this sense.
(iii)
(A) Michael Dillon
https://en.wikipedia.org/wiki/Michael_Dillon   
(1915 – 1962; Laurence Michael Dillon (born Laura Maud Dillon); born in present-day Ireland; In 1945 Dillon enrolled in medical school at Trinity College Dublin under his new legal name)
• Maud (given name)
https://en.wikipedia.org/wiki/Maud_(given_name)
(B) Eton crop
https://en.wikipedia.org/wiki/Eton_crop
• Prince Harry, as well as his older brother Prince William, went to Eton College. So search mages.google.com with (eton college primnce harry or william. On the other hand, neither has worn his hair long in the entire life.
• Eton College Museums and Galleries, June 7, 2019.
https://twitter.com/etoncollmuseums/status/1136984098466082816
(iv) Search images.google.com with children's toilet, and you will see it looks like a small urinal but made of plastic, not ceramic.
(v) "His [Ben's] penis was a respectable length by any measure. It was thicker and paler than any I had personally seen"

D'Arpa S et al, Pre-expanded Anterolateral Thigh Perforator Flap for Phalloplasty. Clinics in Plastic Surgery, 44: 129 (2017)
is locked behind paywall but a photo showed the outcome which is attachment 3.
(vi) American Pie (film)
https://en.wikipedia.org/wiki/American_Pie_(film)   
(1999; "The title refers to a scene in which the protagonist is caught masturbating with a pie after being told that third base feels like 'warm apple pie.' Writer Adam Herz has stated that the title also refers to the quest of losing one's virginity in high school, which is as 'American as apple pie' ")
(vii) "Coloplast Titan"
(A) Coloplast
https://en.wikipedia.org/wiki/Coloplast
("was founded in 1957 by Aage Louis-Hansen" in Denmark)
(B) Titan Penile Implant. Coloplast, undated
https://www.coloplastmenshealth. ... ble-penile-implant/
, where the left panel shows an animation (which is semi-transparent and one hardly sees anything), and right panel shows a real person (whose penis I am unsure of its authenicity)/
(viii) King Missile
https://en.wikipedia.org/wiki/King_Missile