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570-2270</span></span></li> </ul> </nav> </div> </header> <div class="masthead"> <div><img src="https://marcibowers.com/wp-content/uploads/sites/3/2013/09/masthead_image2.jpg" alt="" style="max-width:100%;" /></div> </div>  <section class="main container"> <div class="column span-3"> <div class="column-box" style=""> <article id="post-94" class="post-94 page type-page status-publish hentry"> <header class="entry-header"> <h1 class="entry-title">Preparation (GAV)</h1> </header> <div class="entry-content"> <h3>Medical History</h3> <p><span style="font-weight: 400">If you have any heart problems, you must provide a letter of surgical clearance from a cardiologist. Other major medical problems, such as diabetes, cancer, HIV, etc., will also require specific lab work and clearance. Please contact the office 6 months prior to surgery if you have major medical problems.</span></p> <h3>Sperm Preservation</h3> <p>If you are thinking of preserving sperm, consider <a href="https://www.meetfellow.com/kit-plus-cryo">Fellow</a> . Produce your sample in the convenience of your own home and mail it back for analysis and cryopreservation. Email us if you have any questions or would like to order a kit from our office. </p> <h3>Genital Hair Removal</h3> <p><b>Hair removal in the genital area is highly recommended.</b><span style="font-weight: 400"> Traditional intra-operative electrolysis, as Dr. Bowers has done for years is, in her opinion, incomplete, owing to the large number of hairs in the area. in 2018 she began a 2-part intra-operative approach. Along the lines of hair transplant surgeons, Dr. Bowers individually removes each visible hair follicle in its entirety—this is the most thorough and definitive method for hair clearance. Dr. Bowers follows this clearance with the traditional electrolysis/cautery of remaining follicles. Again, more thorough but incomplete nonetheless. Internal hairs are normally a minor finding and rarely cause symptoms and do not cause infection (as opposed to popular mythology). However, no one wants a hairy vagina. Dr. Bowers has now employed a 2- prong approach to assure<em> complete hair clearance</em> at surgery by excising as many hair follicles <em>in their entirety</em>, similar to how hair transplant surgeons harvest hairs. Secondly, surgical electrolysis is utilized. With this combination, hair in the vagina is much less likely. However, most patients have many hairs. Pre-surgery electrolysis or laser helps immensely in reducing the number we must deal with in surgery.</span></p> <p>Below is a description of which areas we recommend treating:</p> <p><b>The Scrotal Sac (1)</b><span style="font-weight: 400"> (most important): Hair follicles will be removed. Residual follicles are electrolyzed during surgery, but hair growth cycles prevent us from getting all of the dormant hair. Remove hair from the top portion of the scrotum to just above the perineum, and along the midsection extending to the groin crease.</span></p> <p><b>The Penile Shaft (2) </b><span style="font-weight: 400">(important): Skin from the penile shaft and mid-scrotum will be utilized in creation for the new vagina.</span></p> <p><span style="font-weight: 400">Thus, these areas are most important to be clear of hair prior to surgery. Remember to plan ahead. You will need multiple hair removal treatments over a 5 – 6 month period (usually 3 – 5 clearings for laser, 5 – 8 for electrolysis) to ensure effective and permanent hair removal. Please stop hair removal treatments at least three weeks prior to your surgery to permit the area to heal and recover.</span></p> <p><img decoding="async" class="aligncenter size-large wp-image-3641" src="http://marcibowers.com/transfem/wp-content/uploads/sites/3/2021/06/IMG_0055-1024x896.jpg" alt="" width="604" height="529" srcset="https://marcibowers.com/transfem/wp-content/uploads/sites/3/2021/06/IMG_0055-1024x896.jpg 1024w, https://marcibowers.com/transfem/wp-content/uploads/sites/3/2021/06/IMG_0055-300x263.jpg 300w, https://marcibowers.com/transfem/wp-content/uploads/sites/3/2021/06/IMG_0055-768x672.jpg 768w, https://marcibowers.com/transfem/wp-content/uploads/sites/3/2021/06/IMG_0055-1536x1345.jpg 1536w, https://marcibowers.com/transfem/wp-content/uploads/sites/3/2021/06/IMG_0055-2048x1793.jpg 2048w" sizes="(max-width: 604px) 100vw, 604px" /></p> <p><span style="font-weight: 400">In general, we recommend laser hair removal when the scrotal hair is dark, which absorbs the laser energy. It’s less painful and time-consuming than electrolysis, and our experience is that with the proper laser it is permanent with 3 – 4 treatments.</span></p> <h3><strong>Looking for someone to do the genital hair removal? <a href="http://marcibowers.com/transfem/genital-hair-removal/">We’ve compiled a list.</a></strong></h3> <h3>Psychiatric Evaluations</h3> <p><span style="font-weight: 400">Despite our support of the upcoming World Professional Association for Transgender Health (WPATH) Standards of Care to Version 8, your insurance will likely require </span><b>two letters of recommendation, both from mental health professionals.</b><span style="font-weight: 400"> Your pre-authorization will likely not be successful if you can’t provide the letters of recommendation to their satisfaction. We continue to pressure insurance companies to update their requirements. Insurance companies also generally require letters of recommendation be <strong>written within 6 months of surgery</strong>. Feel free to get onto our surgery schedule, and provide the letters of recommendation closer to the surgery date. </span></p> <p><span style="font-weight: 400">If you are a private pay patient (no insurance) and have lived full time in the <em>preferred gender for more than 5 years</em>, we will accept a single letter of recommendation from a doctorate level therapist. It must be written within a year of your surgery date. The standard of care are expected to update by January 2022 to Version 8. </span></p> <h3>Looking for a local therapist? <a href="http://marcibowers.com/transfem/database-for-therapists/">Find one here.</a></h3> <p><span style="font-weight: 400">Dr. Bowers and Dr. Gunther require </span><b>one letter from a PhD or MD therapist/psychiatrist</b><span style="font-weight: 400"> and </span><b>a second letter from any licensed therapist.</b><span style="font-weight: 400"> Specifically, both letters must include the following:</span></p> <ul> <li>A professional header </li> <li>The date the letter was written</li> <li>The provider’s signature</li> </ul> <p> As well as the following content: </p> <ul> <li style="font-weight: 400"><span style="font-weight: 400">The patient’s general identifying characteristics;</span></li> </ul> <ul> <li style="font-weight: 400"><span style="font-weight: 400">The initial and evolving gender, sexual, and other psychiatric diagnoses;</span></li> </ul> <ul> <li style="font-weight: 400"><span style="font-weight: 400">The duration of their professional relationship including the type of pyschotherapy or evaluation that the patient underwent;</span></li> </ul> <ul> <li style="font-weight: 400"><span style="font-weight: 400">The eligibility criteria that have been met and the mental health professional’s rationale for hormone therapy or surgery;</span></li> </ul> <ul> <li style="font-weight: 400"><span style="font-weight: 400">The degree to which the patient has followed the Standards of Care to date and the likelihood of future compliance;</span></li> </ul> <ul> <li style="font-weight: 400"><span style="font-weight: 400">Whether the author of the report is part of a gender team;</span></li> </ul> <ul> <li style="font-weight: 400"><span style="font-weight: 400">That the sender welcomes a phone call to verify the fact that the mental health professional actually wrote the letter as described in this document.</span></li> </ul> <p><span style="font-weight: 400">The readiness and eligibility criteria are outlined below:</span></p> <p><span style="font-weight: 400">The </span><b>minimum eligibility criteria</b><span style="font-weight: 400"> for various genital surgeries equally apply to biologic males and females seeking genital surgery. They are:</span></p> <ul> <li style="font-weight: 400"><span style="font-weight: 400">Legal age of majority in the patient’s nation;</span></li> </ul> <ul> <li style="font-weight: 400"><span style="font-weight: 400">Usually 12 months of continuous hormonal therapy for those without a medical contraindication.</span></li> </ul> <ul> <li style="font-weight: 400"><span style="font-weight: 400">12 months of successful continuous full time real-life experience living as the preferred gender.</span></li> </ul> <ul> <li style="font-weight: 400"><span style="font-weight: 400">Periods of returning to the original gender may indicate ambivalence about proceeding and generally should not be used to fulfill this criterion;</span></li> </ul> <ul> <li style="font-weight: 400"><span style="font-weight: 400">If required by the mental health professional, regular responsible participation in psychotherapy throughout the real-life experience at a frequency determined jointly by the patient and the mental health professional. Psychotherapy per se is not an absolute eligibility criterion for surgery;</span></li> </ul> <ul> <li style="font-weight: 400"><span style="font-weight: 400">Demonstrable knowledge of the cost, required lengths of hospitalizations, likely complications, and post surgical rehabilitation requirements of various surgical approaches;</span></li> </ul> <ul> <li style="font-weight: 400"><span style="font-weight: 400">Awareness of different competent surgeons.</span></li> </ul> <p><span style="font-weight: 400">The </span><b>readiness criteria</b><span style="font-weight: 400"> include:</span></p> <ul> <li style="font-weight: 400"><span style="font-weight: 400">Demonstrable progress in consolidating one’s gender identity;</span></li> </ul> <ul> <li style="font-weight: 400"><span style="font-weight: 400">Demonstrable progress in dealing with work, family, and interpersonal issues resulting in a significantly better state of mental health; this implies satisfactory control of problems such as sociopathy, substance abuse, psychosis, suicidality, for instance).</span></li> </ul> <h3>Suitability for Surgery</h3> <p><span style="font-weight: 400">Please note that the final determination indicating acceptance for surgery is made by Dr. Bowers at your pre-op visit or by Dr. Gunther at your required in person consultation. Consultation prior to setting a surgery date is offered, but not required, if you are in the area. <em>Video</em> and <em>phone consults</em> are also an option. We require a $50 deposit to hold the consult date. If you cancel with less than one week notice you will lose this deposit, so be sure to let us know if your contact information changes!</span></p> <p><b>Acceptance criteria include:</b></p> <ul> <li style="font-weight: 400"><span style="font-weight: 400">Maximum BMI of 40. If you are over this BMI (regardless of proportion or level of fitness), you must let your surgeon know in advance; they will contact you to determine if surgery should be postponed. Surgery simply takes longer in heavier patients and puts you at greater risk for complications. </span> <ul> <li>There is an absolute BMI limit of 40. This means if you arrive heavier than that weight, you will potentially lose the $1,000 surgery deposit and be rescheduled.</li> </ul> </li> </ul> <ul> <li style="font-weight: 400"><span style="font-weight: 400">Non-smoker (unless specifically exempted by Dr. Bowers or Dr. Gunther). For smokers, tissue healing is truly poorer and the risk of surgical complications greater.</span></li> </ul> <h3>HIV Status</h3> <p><span style="font-weight: 400">Please send an HIV result from an accredited laboratory performed within 12 weeks of surgery. HIV- Status, however, is not a prerequisite for acceptance for surgery. (contact Dr. Bowers specifically regarding her criteria).</span></p> <h3>Skin Grafting</h3> <p><span style="font-weight: 400">The need for non-scrotal skin grafting to create the neovagina is very rare. Skin from the scrotal sac is preferred as the graft-donor site and allows us to almost always have enough skin to achieve suitable vaginal length. Grafted skin from the lower abdomen, buttocks, or pooled donor skin matrix such as Repliform or <strong>DermaPure</strong> is possible. Skin from one’s own body is always preferable. A newer technique is <strong>peritoneal grafting</strong> but the remains experimental and is best reserved for those who need additional skin not available in the above methods. That said, there is always a component of penile inversion in order to communicate with the peritoneum. Don’t be fooled. It also requires laparoscopy at the time of GAV. Peritoneal grafting is currently available while Dr. Bowers is in New York at Mt. Sinai but not currently available in Burlingame. If you do consider yourself to be on the unusually small size, or have specific requirements or expectations for post-surgical depth please include that information in your medical history and consider a consultation with Dr. Bowers well prior to your expected surgery date.</span></p> <p></p> </div> <footer class="entry-meta"> </footer> </article> </div> </div> <div class="column span-1 last"> <aside> <div> <ul class="socialicons clear">  <li class="icon facebook"><a href="http://www.facebook.com/GenderSurgery" target="_blank">Facebook</a></li> <li class="icon linkedin"><a href="http://www.linkedin.com/pub/marci-bowers/5/377/343" target="_blank">Linkedin</a></li> </ul> </div> <div> <div class="tertiary sidebar-container" role="complementary"> <div class="sidebar-inner"> <div class="widget"> <aside id="search-2" class="widget widget_search"> <form role="search" method="get" id="searchform" action="https://marcibowers.com/transfem/"> <input type="text" class="text" placeholder="Search this site" name="s" id="s" /> </form></aside><aside id="nav_menu-2" class="widget widget_nav_menu"><div class="menu-footer-navigation-container"><ul id="menu-footer-navigation" class="menu"><li id="menu-item-68" class="menu-item menu-item-type-post_type menu-item-object-page menu-item-68"><a href="https://marcibowers.com/transfem/privacy/">Privacy Policy</a></li> </ul></div></aside> </div> </div> </div> </div> </aside> </div> <footer class="footer-main"> <div class="column-box clearfix"> <div class="column span-3"> <span>Copyright ©2025 Marci L. 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