The labia majora will become the scrotal sac. Pockets for the testicular implants are created in each labia majora by utilizing the vacant space left previously occupied by the round ligaments. These two pockets will accommodate individually customized solid silicone testicular implants, which are placed in the pockets by insertion through the incision site in the “mons” and traveling down the tunnel through the tissues that once held the round ligaments. Later in the procedure, the two halves of the new scrotum will be conjoined to generally form an anatomically and aesthetically correct scrotal sac. Where the round ligaments once held in the labia majora up, their absence now will allow the tissue to stretch out and down over time such that in about three months time, a fairly typical scrotal sac will be evident upon inspection.

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, and 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. To further support the neo-urethra and its new direction upward through the neo-phallus, muscle tissue from both side of the immediate area around the base of the neo-urethra are gathered and sutured together. This, in effect, helps to shore up or strengthen the repairs made in the area, such as the closure of the vaginal opening, by holding the h2est tissue (the muscle) in close proximity thereby helping prevent overstretching or tearing of the more fragile or repaired tissues in that area.

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 six months after the initial procedure. One of the advantages of the Centurion is that it provides more girth to the neo-phallus. The presence of the round ligaments also adds an additional layer of support and insulation to the neo-urethra that mimics the anatomy of the native male penis.

The habit that most profoundly and negatively affects recovery is tobacco abuse. Cigarettes contain nicotine, which is a proven vasoconstrictor, depressant, and a 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.

For many transmen patients, GCS is a vital component of their transition, offering many physical and psychological benefits. Because GCS is such a significant procedure, it is paramount to work with only the most expert surgeons. At the International Center for Transgender Care, our board-certified surgeons have more than 20 years of experience treating transgender patients. We are proud to offer all of our services in a respectful, welcoming environment at our world-class surgical center in Dallas, Texas. We look forward to assisting you in achieving the very best possible results for your GCS. Contact us today to schedule a consultation or call us at (972) 543-2477.