My SRS Experience with Dr. Gary Alter

By "Rachel;" edited by Anne A. Lawrence, M.D., Ph.D.

Saturday, 20 May 2000

Today begins the journaling of my SRS experience with Dr. Gary Alter in Los Angeles. My journaling of this event is in part to provide the community with more information than is currently available about Dr. Alter and his work. Dr. Alter is a relative newcomer on the SRS scene, and consequently there are not many examples of his work to be seen, and no published testimonials, at least that Iíve been able to find.

Dr. Alter is a plastic surgeon who works in Beverly Hills, California, and who, in addition to general plastic surgery, specializes in genital reconstructive surgery -- not just in transsexual women but in natal women as well. His work in this area has been documented in two womenís magazines, Cosmopolitan and Marie Clare. Taken from his own website is the following statement: "Gary Alter, M.D. is one of the rare doctors (only two in the United States), who is certified by both the American Board of Plastic Surgery and the American Board of Urology. He specializes in genital reconstruction and facial and body surgery for transgender patients."

I had occasion to first meet Dr. Alter at a seminar hosted by the Los Angeles Gender Center in December of 1998. I had only just come out and wasnít yet presenting enfemme and was very shy about asking questions. However, there were about 35-40 people at the seminar so virtually every question I had, as well as some I hadnít thought of, were well covered that day. His answers were always clear and concise and given in terms anyone could understand.

One of the things that impressed me so much that day, and still does, is Dr. Alterís devotion to attention to detail. He explained, as he does at his site, that his "goals in SRS surgery are to create as normal a vagina and introitus as possible, provide maximal clitoral and vaginal sensation, furnish a deep vagina allowing satisfactory sexual intercourse, and minimize disfiguring scars." Indeed, he explained that his SRS surgery is an all day affair, requiring 8 to 9 hours to complete. He explained that his intent is to sever as few nerve connections as possible. In addition, one of his patients, obviously very excited about her results, got up to speak her praise of the doctors work. Her story was most compelling. In fact, I have corresponded with her I recent months, to ask if she still feels the same way -- she does.

Dr. Alter is not inexpensive; in fact, I believe he is probably the most expensive SRS surgeon out there, but in my opinion he is worth the money. The surgeonís fees are a little over $10,000, and the hospital and anesthesiologistís fees add another $12,500. I believe this is the single most important surgery Iíll ever have (Dr. O is a close second), and I want it done well. The issue of price, although obviously important, is secondary to me.

For myself, the important deciding factors in choosing Dr. Alter are:

a. Vast experience in genital surgery, including vaginal surgery in natal women
b. Experience in urology as well as plastic surgery
c. Extreme attention to detail
d. Proximity to my home (about 20 miles)
e. Proximity to Rodeo Drive (about 2 blocks)
f. All around nice guy
Dr. Alter performs his procedures at Century City Hospital in Century City, a short distance from his office in Beverly Hills. So far, my experience there has only been a single visit to self donate a unit of blood, which I will repeat again this coming Monday. That experience was very frustrating in the beginning, dealing with the administrative people, but once up on the nursing floor, I was very pleasantly surprised by the courteous, professional and compassionate manner with which I was treated. This coming Monday, I have my pre-op appointment with Dr. Alter, which I am anxiously awaiting.

Thursday, 1 June 2000

My appointment time last week turned out to be incorrect, so I saw Dr. Alter for my pre-op appointment today instead. I was quite nervous and had a lot of questions, which seemed more difficult for me to ask in person. I was very happy to have my friend Magi there to help see me through.

Dr. Alter answered all of my questions at great length and with due respect to my state of mind, and to my satisfaction. His assistant, Xena, gave me a sheet of pre-operative instructions to follow. I left his office this day with little fear of June 13th, other than the normal pre-op jitters anyone might feel before going under general anesthesia. But I also left his office with a new and wonderful excitement about my entire future.

The last few days were quite hectic for me, the way it would be for anyone about to take a seven day vacation. I had my two children with me up until the second night before surgery, and we were all excited that day by a large brushfire that came to within a half mile of our home. So there were enough distractions to do an adequate job of keeping my mind off the impending surgery.

Monday, 12 June 2000

Today I am very much at ease. In stark contrast to my extreme fear prior to my visit to Dr. Osterhout last March, I am wonderfully calm today. Tonight, the producers and the film crew that will document the surgery tomorrow are coming to my home to interview me. Iím not sure how I feel about all of this, but they seem like decent people, and The Learning Channel seems like a good place for this story. Although we talked about the surgery for most of the 3 hours of on-camera interview, it strangely distracted me from being nervous about it.

Tuesday, 13 June 2000

My friend Magi and I arrived at Century City Hospital at about 5:15 am, and my spirits were definitely way up. I was asked to step into the admitting office to make the hospital payment, where I was met by yet another unpleasant administrative person. We had a disagreement and I reminded her that I was a customer of the hospital, paying for elective surgery out of my own pocket and could make the choice to leave then and there which she would then have the duty of explaining to her superiors. She quickly saw the situation differently and all was finished there. I was taken up to the 4th floor, where I was prepped for surgery and had final discussions with Dr. Alter and the anesthesiologist. There were a few questions from the film crew and the next thing I knew, Dr. Alter was telling me that it was all done! He told me that the 7-1/2 hour procedure went perfectly and that everything looked fine. He said I was doing great and that heíd be back to see me the next day. I am sure that I had a myriad of questions for him but I was too out of it to ask him anything. I remember little from that night, actually, other than that there were some calls (not sure who). Magi was with me until quite late, and I didnít seem to be in much pain. I did feel a need to use the PCA morphine pump a few times that night.

Wednesday, 14 June 2000

I awoke early on Wednesday, feeling quite wonderful. Rested and cheery, full of life and energy. Incredibly happy in fact! There was minimal pain, and I chose not to self- administer any morphine during day. Of course, there was still a minimal amount of morphine being administered throughout the day by the machine. Still I was amazed at the low level of discomfort. Breakfast was at about 8:00 am, which was actually quite good for hospital food, and then a nice little sponge bath refreshed me. Dr. Alter came by to see me just after 10 am to check out his handiwork. It seemed the first matter of order for him was to check the sensitivity of my new clitoris. Yikes! It was indeed sensitive. He talked to me a bit about the procedure and asked if I had any questions but I was still way too excited about it all to think of anything at that time, so he said that although heíd be in to see me every day, it was now just a matter of lying in this bed for 6 days and healing. I do want to mention that the staff at this hospital are incredible. They are professional, attentive and very concerned for their patients.

Thursday, 15 June 2000

More of the same today; the care and attention by Dr. Alter and the staff here are wonderful, but one can only count the windows in the building across the street just so many times before going batty! The point is, nothing new happens: you just continue lying here, healing, and watching Donny and Marie. Since I live in the area, at least I have plenty of visitors, which is a great distraction from boredom.

Monday, 19 June 2000

Going home today! Canít wait!

Wednesday, 21 June 2000

My sisters, Gale and Debbie, arrived from Seattle today to help care for me. Walking is tough, but there is still very little pain. Gale took a peek at my new vagina today, and despite its swollen condition, she says it looks very real.

Saturday, 24 June 2000

Tonight I was given the most wonderful party by my sister Gale and my best friend Jackie. There were 35 people there to wish me a sort of "Bon Voyage" as the next part of my journey is beginning. There was dinner, a full bar and a wonderful DJ. The most amazing part is that I am up and dancing until 1 am, less than two weeks post surgery. Maybe I did take on too much, but it is still a testament to my recovery ability.

Thursday 20 July 2000

Oh my God! Just 5 weeks after surgery I have just, unmistakably, experienced orgasm! And it was good, very, very GOOD! If only I had someone to share it with. I was so certain that this would never happen again. I am thanking Dr. Alter for his great surgical care and attention again right now.

Saturday, 29 July 2000

Back now from a 3-1/2 week, 4300 mile road trip up the US West Coast, where I spent a great deal of time with my family in Seattle, I have more questions than ever. In spite of all of the angst that I am dealing with right now, at least I have the comfort of knowing that my transition was indeed the right path for me. I am quite happy with the results of my surgery, it looks right and works right and I am very happy with the work that Dr. Alter performed on me. I continue to experiment with my newfound orgasmic response. I noticed also that there is a clear sticky fluid being excreted from my urethra during these delightful experiments.

Saturday, 12 August 2000

Today was disaster day. The dull throbbing pain that Iíve felt in my lower left leg the last few days greatly intensified this morning. I am usually very active physically, although I havenít been to the gym for a workout since my surgery, under the good doctorís orders of course. We had planned to take the kids out boating tomorrow, so I went to the storage place to get the boat. In the past the task was never a difficult one but today was much different. The pain in my leg was much stronger when I finished that when I had started.

We stopped on the way home for a smoothie and I found I could hardly walk. I looked down at my leg to see that my left calf was swollen to twice its normal size. I was quite frightened, and called my doctor from my mobile phone on the way home. But today being Saturday, no one was in the office. However, his associate, Dr. Barnett, was on call. It is interesting to note that I thought to call my regular doctor, rather than Dr. Alter, even though at the time I thought this must be due to my surgery on June 13th. I am sure now that I was in a panic mode at the time.

Dr. Barnett called me soon after I got home and I described to her what was happening. She didnít hesitate at all in advising me to get into the emergency room at Cedars-Sinai straight away. Her thought was that I had developed a blood clot in my leg.

My friend Magi drove me down to Cedars and I saw a triage nurse in the emergency room within 10 minutes. A couple of hours later, I was on a gurney somewhere upstairs having a Doppler ultrasound being done on both legs. A short while later I was admitted as a patient at about 8:30 diagnosed with DVT (deep venous thrombosis) -- blood clotting. On the Doppler monitor, the tech had shown me the extent of the clotting: one started from just above my knee and extended to my ankle and several smaller ones were found just at the top of my leg, in my groin area.

Of the three residents that I saw, none of them failed to explain the extreme danger of my condition. There was the possibility that a piece of any of those clots could break off and find its way to my lungs, where, depending on its size, it might do serious damage, possibly even death. Needless to say, my emotional state at this point was very severe. Fear and panic set in, and I start to ask the inevitable question, "Why? "

Before I decided to follow this path, I was healthy, hardly ever being in a hospital at all. "How did I get here? " I asked. Nearly 2 years on hormones, two major elective operations in the last 6 months, a year and a half of visits to Dallas having large amounts of lidocaine and epinephrine shot into me until my heart beat so fast it scared me. Am I here now as a result of all of that? Magi tried her best to calm me, but I wasnít going to put my extreme emotions to rest.

The doctors began an IV with a drug called heparin, which is a blood thinner. This would insure that the clot would not advance and might perhaps even dissipate somewhat.

Sunday, 13 August 2000

Dr. Barnett came by today to verify what I already knew, and to explain what might be done over the next few days. She said that the heparin therapy would be used for 7-10 days in the hospital, and would result in a passageway being made through the clot to allow for nearly normal blood flow. That would be followed by a procedure in which a filter, a small umbrella shaped basket, would be inserted in my main vein to catch any particles of the remaining clot that might happen to dislodge in the future. Then I would be put on an oral drug, Coumadin, that would be required for up to 24 months. This news was good, in that it would save my leg, and would save my life; but I feared that I would not be able to live the normal active life of which I have grown so fond. I am still scared, very, very scared.

Monday, 14 August 2000

Today my own doctor, Dr. Richard Horowitz, came to evaluate my condition and relieve Dr. Barnett. He had already seen the results of the Doppler ultrasound and had spoken with the resident vascular expert, Dr. Richard Van Allen. Dr. Van Allen suggested that for me, another way to go would be a lysing procedure using the drug TPA, also a blood thinner. The successful result of this procedure would be that after just 24 hours of administering TPA, the DVT would be completely eradicated and would negate the need for any further procedure, including the filter placement. Of course, oral drug therapy using Coumadin would also be necessary, but perhaps only for 90 days.

This procedure is also dependent on the age of the DVT, which had not been accurately determined by the Doppler ultrasound. If older that 2 weeks, this procedure would be too risky, in which case we would have to revert to the heparin therapy and subsequent filter placement.

Sounds great; but, of course, this unique procedure is not without its own unique danger, that being a very high risk of hemorrhaging, from spot bleeding up to cerebral hemorrhaging during the time that the TPA would be administered. It was noted that probably I was at a lower risk for this because of my age and health and lack of a personal or family history of DVT. So, it was decided today that tomorrow we would begin.

Tuesday, 15 August 2000

This morning, quite early, I was whisked to the awesomely ominous vascular area for an angiogram. After I awoke from what seemed like a 1960s experience, Dr. Van Allen showed me the result he had found on the monitor. It was a much clearer picture of the full extent of my condition than could be seen by the ultrasound. The clot was a monster, but luckily it was a relatively young one, meaning that it was most likely NOT caused by my surgery two months ago. I now knew myself what the cause probably was; I just didnít want to admit it to myself. Dr. Van Allen began the TPA, and I was sent to recovery and then to ICU.

Wednesday, 16 August 2000

Just about 24 hours later, I am once again in the hands of the very handsome Dr. Van Allen and his delightful crew and those big, scary, ominous machines. Because I still had in my leg the catheter they put in my yesterday, they didnít put me as far under today, which was OK because I didnít really like the 60s anyway. So I was mostly awake for the seemingly short angiogram procedure. I was most certainly awake enough to see that there was no color in the vein depicted on the monitor. I already knew what that meantÖ the clot was gone! Not just dissipated, it had vanished! Would anyone doubt that I cried just then?

Back up to ICU to wait for a room on a lower floor, a room that is for patients who are on their way to recovery, and on their way home. I am OK and in a few days, I am going home!

Sunday, 20 August 2000

I have been home now since Friday afternoon. There is pain in my leg when it is not elevated, mostly when I walk; but as Dr. Horowitz explained, this is just due to the fact that my vein was has been irritated, and now when the blood flows through the damaged area it hurts. But that will go away.

I want everyone who reads this to know what caused this to happen to me.

I did. Plain and simple, I did.

NOT because I decided on this path in life, but because I didnít follow one of the basic ruleÖ Let those that know make the recommendations -- listen to your doctors!

After my surgery on June 13th, I think I got sort of "cocky," a strange term for someone like me to use, but itís true. I had to discontinue hormone use for 30 days prior to my surgery and suddenly, after surgery, I was not particularly happy with what I had lost in terms of breast mass. Both Dr. Alter and Dr. Horowitz told me it would come back, but I was impatient.

So when Dr. Alter sent me home from my surgery and said that I could start my previous hormone therapy again, I guess that I decided to give the process a jump start and I cheated on my doses, ever so slightly mind you, but I took more than what I had been taking prior to surgery. I wanted my boobs back! The result was a swift, uninsured, kick in my pretty little ass -- a lesson, if you will, in what so many of us take for granted: our health.

When I first started on this journey, I self-medicated for 6 months. It seemed OK because, it seemed that so many people were doing it. And while it worked for me then, my arrogance made me think I was invincible, so I did it again.

I guess what I am saying is that if this can happen to me, a relatively young and very healthy person, who only slightly increased an already-prescribed dose, then it could theoretically happen to anyone. Please, I hope that anyone who considers taking hormones does so under a physicianís care. I could have died. I was lucky.

Tuesday, 22 August 2000

I am lying here with an aching leg and a huge acrylic rod in my groin, wondering if I have really gotten across my sentiment about Dr. Alters work. I think it represents the current state of the art in SRS surgery. My sexual sensitivity is fantastic, and the intensity of my orgasms is overwhelming. I also want to make clear that I don't feel that Dr. Alter was to blame in any way for my DVT. That responsibility lies solely with me.

With great love and respect for all of those who are on this path,


© 2000 by Anne A. Lawrence, M.D., Ph.D. All rights reserved.