The Centurion Procedure
Updated December 4, 2003
This information is out of date. Updated information to be posted soon!
To view pertinent posts about the procedure from Dr. Tex McFadden, visit the new area of the T-Male site:
http://www.thetransitionalmale.com/centurion_posts
Centurion Background
Over the years, Peter Raphael, M.D. has worked with patients from all walks of
life. While their needs have varied, their goals have centered on finding
a way to make their outer appearance reflect their inner self-image.
Along the way, gender dysphoria patients making the female-to-male transition
approached Dr. Raphael seeking an improvement over the existing metaoidioplasty
and phalloplasty procedures. The dilemma of devising such a procedure
centered on how to create a penis that might have the potential to retain
sensation and some level of function. Medical literature reviews revealed
the failures of various types of grafts, including poor aesthetics, the
potential for high rates of morbidity, necrosis, sepsis, and permanent erectile
dysfunction.
In his efforts to achieve such an improvement, Dr. Raphael continues to refine
the Centurion and works in conjunction with gynecologic oncologist Alan Munoz,
M.D. in this endeavor. An expert in his field, Dr. Munoz' input has been
invaluable in implementing Dr. Raphael's Centurion innovations, particularly
with their innovation of a new vaginoplasty technique.
Dr. Raphael's success and patient satisfaction has been enhanced by the
continuity of care and personnel who work with the transgender/gender dysphoria
(TG/GD) patients during the female-to-male (FTM) process.
Patients can expect knowledgeable consultants and staff to expertly assist them
with their inquires, consultations, surgery scheduling, and finance options, as
well as a fine anesthesia department to diligently monitor them from the pre-op
area, through surgery, and into the recovery room.
The American Institute for Plastic Surgery and the Summit Surgery Center
constantly strive to provide all patients with a solid core of compassionate,
competent medical staff who will answer their every question, assist them in
preparing for their surgery, and follow their care and progress from initial
contact until long beyond final recovery.
The Centurion Procedure
The first Centurion procedure was performed in June 2002 and is typically
performed in conjunction with a vaginoplasty and a hysterectomy with bilateral
salphingo-oopherectomy. The hysterectomy with bilateral salphingo-
oopherectomy and a vaginoplasty requires approximately 1.5 hours to
perform. The Centurion procedure takes approximately 2.5 hours.
Every patient's anatomy varies, thus surgery time can also vary. The most
important, yet variable, component in constructing a neo-phallus is the amount
and type of available tissue. When less tissue is available to recruit
for constructing the various structures, the surgery will naturally take longer
to complete. Recovery times after surgery will vary, but patients should
expect to be limited in their physical activities during the initial two to
three
weeks and gradually increase over time. All of the restrictions are
thoroughly discussed with each patient by Dr. Raphael and his staff on an
ongoing basis.
If the patient requires a hysterectomy and bilateral salphingo-oophorectomy,
then Drs. Raphael and Munoz first step is to perform an abdominal hysterectomy
prior to proceeding with the vaginoplasty. If no hysterectomy is
required, the surgeons will enter the abdomen through the same incision site
previously used for the patient's hysterectomy and perform the vaginoplasty.
Dr. Raphael's vaginoplasty technique is his innovative approach, conceived and
refined with Dr. Munoz' input, to safely deal with the native vaginal tissue.
The traditional vaginectomy carries a high morbidity rate due to risk
of injury to any number of nearby critical organs, including the abdomen,
bladder, bowel, and rectum. Considering these risks and noting the
importance of vaginal tissue with regards to proper bladder function, the
surgeons brainstormed this new technique to significantly reduce morbidity and
to maintain proper bladder function.
The vaginoplasty effectively closes the vagina in a safer and more efficient
manner by opening the vagina from above in the abdomen and then closing it at
the lower native opening. This essentially reverses the original
configuration where the vagina is naturally open at the bottom and closed at the
top, at the abdomen wall. This eliminates the potentially risky dissection
of the vaginal tissue required with a vaginectomy and leaves the crucial tissue
in place to continue to regulate bladder function. The vaginoplasty
essentially creates a new pocket at the bottom of the abdomen. Any fluids
secreted by the vaginal tissue will simply be absorbed, processed and dealt
with/excreted by the body in typical fashion as are any fluids arising anywhere
in the human body.
Once the vaginoplasty is complete and the abdominal incision is closed, Dr.
Raphael and his surgical team continue the procedure by releasing the clitoris
at the chordee. The suspensory ligaments are left intact to provide
support. The erectile nature of clitoris will provide the basis of the
neo-phallus erection post-operatively. The round ligaments are distally
(meaning farthest from the body) dissected free from the labia majora but left
attached at their proximal (meaning closest to the body) attachments. The
freed proximal ends will be joined just below the "head" of the
clitoris, thus forming the head of the neo-phallus. The round ligaments,
although not erectile in nature, provide girth along the length of the shaft of
the neo-phallus.
The labia majora will become the scrotal sac. Pockets will be created in
each labia majora, utilizing the vacant space left after the round ligaments
were dissected out. These two pockets will accommodate the individually
customized solid silicone testicular implants and will later be conjoined to
form an anatomically and aesthetically correct scrotal sac.
The challenging portion of any Centurion is creating the neo-urethra. The
neo-urethra begins at the native urethra opening, typically consists of three
conjoined flaps, and ends at the head of the neo-phallus. The availability
of tissue to create these flaps is the limiting factor in the number and length
of the flaps, thus the overall length of the new urethral extension. The
more tissue that can be recruited for the neo-urethra, the longer the
neo-urethra can be and thus the longer the neo-phallus.
The flaps that are recruited are wrapped around the foley catheter tube, which
was placed prior to the start of the Centurion procedure. Each flap is
carefully joined, beginning at the native urethra, until all flaps have been
joined around the foley catheter and to each other. Thus, the neo-urethra
fully encloses the catheter, which will serve as a pseudo-stent while the
neo-urethra heals and the flaps integrate to form one continuous tube.
At this stage, all that essentially remains is closure. Beginning with the
tissues beneath the superficial skin, the two halves of the scrotal sac are
joined and sutured together, as is the shaft of the neo-phallus. Then,
superficial skin closure is performed, including the original vaginal opening,
the scrotal sac, and the shaft of the neo-phallus.
The patient can expect to have the foley catheter for approximately two weeks
before it may be removed at the surgeon's discretion.
To date, the main issues with this procedure have been occasional testicular
implant extrusion through the suture site, which relates to available tissue and
the health and thickness of the tissue, and neo-urethral stricture or fistula,
which may require routine dilation for a period of time until the neo-urethral
tissues adapt to their new function. Dr. Raphael has recently begun trying
another innovation aimed at reducing the possibility of neo-urethral stricture
by utilizing a "muscle wrap" in the neo-phallus. This new
technique is currently being evaluated in surgical patients. Any necessary
revision is typically done in six months after the initial procedure.
Impacting Recovery
Many things can impact a patient's recovery, regardless of the type of surgery,
but the primary factors are each patient's health and level of fitness. These
are different aspects but both are affected by patients habits and practices and
both in turn will provide a positive or negative impact on post-operative
recovery.
Obviously obesity and poor diet impact recovery in a negative way. They
increase the burden on the body to function and force the body to divert the
limited resources a poor diet provides to dealing with functioning under and
increased "load" on the system in the case of overweight or obese
patients. These factors can impair circulation and the quality of the
blood and the nutrients it provides for the cellular/tissue recovery.
The habit that most profoundly and negatively affects recovery is tobacco abuse.
Cigarettes contain nicotine, which is a proven vasoconstrictor, depressant, and
toxin. While most people associate lung cancer with
smoking, nicotine has effects on all parts of the body. Because the
Centurion procedure involves a small, critical area and a number of tissue
flaps, circulation is crucial to recovery, function, and simply avoiding
infection. Nicotine as a vasoconstrictor constricts, or "shrinks
down", the blood vessels and in an area with small capillaries of a tiny
diameter, any constriction can prove detrimental. As a depressant,
nicotine depresses all natural functions in the human body, including the immune
system. Combine these with the fact that nicotine is a toxin that the body
will expend energy on to combat, and the risk for complications grows
exponentially.
The goal of all patients should be to be as physically prepared as they are
mentally for the FTM change. Those in the best physical condition will
afford themselves the best opportunity for successful recovery and optimal
function. While there are no guarantees, no one should ever make the
mistake of limiting their options by continuing habits or practices that are
harmful or cause the body to divert energy and attention from healing and
function to things that are easily avoidable.
The staff and Dr. Raphael will be happy to answer any questions. You can
be assured that your questions and concerns will be handled in a timely manner
with the utmost confidentiality from the initial discussion to long after your
surgery.
Update! The contact info at the
end can be updated to have them contact Dr. Tex McFadden @ 972-543-2481 or
drtexmcfaden@sbcglobal.net with
questions.
Thank you to Dr. McFadden for sending me a
very informative email allowing me to keep this information up and who will soon
be sending me updates about this procedure!
Thank you to Joshua for sending this valuable information to the T-MALE Site~!