Ways a Physiotherapist Can Help With Preparation and Rehabilitation for Transition-Related Surgeries

If you are considering any transition-related surgery, a pelvic physiotherapist will help you prepare in order to enhance positive outcomes and decrease negative side effects. They can also help to address some physical side effects that are common with transition-related surgeries throughout your recovery process.

As with any surgery, it is important to understand the options that are available, as well as the pros and cons involved with each procedure.

Types of Transition-Related Surgeries:

Chest Feminization Surgery

Chest feminization surgery usually involves breast augmentation. The two types of materials that can be used are silicone or saline. There are typically three placements possible for these materials. The first is subglandular, where an implant is under the breast tissue. This is the more superficial option. The second is submuscular, which is under the pectoral muscles. The third is when the implant is placed partially under the breast tissue and partially under the pectoral muscle.

The different incisions used are dependent on the surgeon, the amount of tissue present, and the shape of the person undergoing surgery. The incisions can be periareolar: around the areola (nipple), transaxillary: in the axilla (armpit), or inframammary: along the bottom fold of where the breast will lie.


Chest Masculinization Surgery

Chest Masculinization surgery involves the removal of tissue and can involve reshaping of tissue with the use of liposuction. There are different incisions and techniques used in order to perform this surgery. The surgery type is dependent on the surgeon, patient preference, the amount of tissue present prior to surgery, and the quality of the skin. The types of incisions are keyhole, buttonhole, lollipop, fishmouth, double incision, periareolar, and inverted T.


Metoidioplasty

A metoidioplasty is a type of surgery that is typically used to create a scrotum and small phallus. A Urologist, urogynaecologist, and/or plastic surgeon will perform this surgery. During this type of surgery, the clitoris, which is enlarged from a person having taken testosterone, is lengthened by releasing it from the hood and the ligament that connects the clitoris to the pubic bone. The labia minora and the subcutaneous tissue from this area can be used to bulk the phallus. The labia are typically connected to create a scrotum. Metoidioplasty can involve many different types of procedures. These can involve urethral lengthening or not, testicular implants, vaginectomy (removal of the vagina), and/or hysterectomy (removal of the uterus).

Phalloplasty

Phalloplasty is a surgery performed by a plastic surgeon, urologist, and/or urogynecologist. This surgery is performed in order to create or repair a phallus. A graft is used from a donor site in order to construct the phallus. The tissue graft can be collected from the forearm, back, leg, abdomen or the groin area. There are different types of phalloplasty. These can involve urethroplasty (constructing and lengthening the urethra), scrotoplasty (constructing the scrotum and inserting testicular implants), glansplasty (constructing the glans of the phallus), vaginectomy (removal of the vagina), and/or hysterectomy (removal of the uterus). Phalloplasty will typically involve several surgeries and is not done in a single stage. For those who wish to have erectile function of the phallus, a penile implant can be installed. This usually takes place approximately 9 months following the final phalloplasty surgeries.


Vaginoplasty

Vaginoplasty is a surgery performed by a urologist, gynaecologist, urogynaecologist, and/or plastic surgeon. This surgery involves creating a vaginal cavity with the appropriate dimensions to allow for penetrative sex, a clitoris that is sensate to erogenous stimulation, an anatomically parallel vulva, and a shortened urethra.

There are different procedures used in order to perform this surgery. The most commonly used technique is the penile inversion surgery. In this surgery, the penis skin and a scrotal flap are used to line the newly created vaginal cavity. Another type of vaginoplasty is the intestinal vaginoplasty, which involves using a portion of the ileum or sigmoid colon to line the vaginal cavity. The last type, which is less commonly used, is the peritoneal pulldown vaginoplasty. It involves the peritoneum (inner lining of the abdominal cavity) being pulled down to an opening created behind the prostate to create the vaginal cavity.

In all vaginoplasty surgeries, the glans of the penis is used in order to create the clitoris. The neuro-vascular bundle is preserved in the goal of maintaining erogenous sensation of the clitoris. Some surgeons offer a surgery that is sometimes referred to as a vulvoplasty, or shallow-depth vaginoplasty. This involves creating a vulva without constructing a vaginal cavity. This can be an option for a person who does not have penetration as one of their goals following surgery.

Pre-Op Role of Physiotherapist

Just as rehab is a vital part of recovery for any type of surgery, “prehab” can be an integral phase in ensuring recovery goes as smooth as possible for all of the transition-related surgeries listed above.

One of the first steps can be optimizing breathing patterns. Whether it be in relation to upper or lower transition surgeries, ensuring that one is using a diaphragmatic breath is vital. By breathing into our lower lungs, we are able to absorb more oxygen, allowing it to supply the body in a more efficient way. Rib mobility, which is something a physiotherapist can help improve, is also a key factor in optimizing breath. Our ribs need to move in order to allow expansion of the chest upon inhalation. Our diaphragm works in coordination with our pelvic floor muscles. A pelvic physiotherapist can assess this coordination and retrain it if needed.

They can also help a person work on pelvic floor proprioception (from the position sense), as well as tension, strength, control, and relaxation. All these elements help prepare a person having a transition-related surgery, and informs them on what they will be working on after the surgery.

Pelvic physiotherapists can help optimize bladder function by establishing pelvic floor muscle coordination and positioning for voiding. They can also provide education on how to avoid certain bladder irritants.

Lastly, improving general strength and mobility through the back, hips, and shoulders will ready the body for surgical positions and train the body for rehabilitation following the surgery.

Post-Op Role of Physiotherapist

Pelvic physiotherapists can help to guide a person throughout their recovery journey after a transition-related surgery.

After most surgeries, breathing patterns can be altered. A physiotherapist can help restore breath by working on rib mobility, muscle restrictions, as well as education on recruiting the diaphragm in order to guide the breath into the lower lungs. By breathing into our lower lungs, we are able to absorb more oxygen, allowing it to supply the body in a more efficient way, which will help with healing.

In addition, there are manual techniques a physiotherapist can use to improve scar and connective tissue healing after any transition-related surgery. They can work on the post-operative scars around the phallus, the vaginectomy or hysterectomy. They can provide education on retraining posture following a change in the body by stretching and strengthening the structures in the neck, the thoracic spine, the chest, and the abdomen. Some physiotherapists can also perform lymphatic drainage, which can help decrease swelling around the phallus.

Our pelvic floor muscles must work in coordination with our diaphragm, deep abdominals and back muscles. A pelvic physiotherapist can assess this coordination and retrain it if needed. They provide training to restore pelvic floor proprioception (the position sense). They can assist in decreasing tension, improving strength, control, and relaxation, which can be altered following surgery in this area.

Pelvic physiotherapists can also guide a person in restoring proper function in their urination and defecation dynamics, which can be impacted by surgery. They can provide support in relearning erogenous zones and sensations. Constipation is a common complaint following any surgery. Pelvic physiotherapy can continue addressing the pelvic floor muscles, breathing techniques, along with fluid and fiber intake after the surgery to help with constipation.


Post-Operative Care for Vaginoplasty

One of the crucial parts of the post-operative care following vaginoplasty is dilation. The tissue wants to heel back to its original position, so dilators are used in order to keep the vaginal cavity open. Depending on the surgeon, dilation may be started between 7 to 14 days following surgery. The surgeon provides a protocol with detailed instructions on the frequency of dilation. Pelvic physiotherapists can support a person with dilation by providing reassurance, options for positioning, relaxation techniques for the pelvic floor muscles, exercises for hip mobility, and breathing exercises to decrease tension in the body. Pelvic physiotherapists can also work on the post-operative scars around the labia, vagina and clitoris after vaginoplasty.