Toby Meltzer

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Toby R. Meltzer, MD (born September 19, 1957), is a plastic and reconstructive surgeon who currently practices in Scottsdale, Arizona. Meltzer specialises in sex reassignment surgery male-to-female, sex reassignment surgery female-to-male, and facial feminization surgery. He has pioneered major advancements in vaginoplasty techniques to create neovaginas, and advancement of the metoidioplasty procedure for creation of a penis from clitoral and surrounding tissue. With 400 to 500 sexual reassignment surgeries (SRS) performed each year, Meltzer is one of the leading SRS surgeons in the U.S. and the world. ^[1]

1 Education and early practice
2 Vaginoplasty technique
3 Other surgeries
4 References
5 External links

[edit] Education and early practice

Meltzer is a graduate of the Louisiana State University school of medicine, where he also completed a residency in general surgery. He then moved to Michigan and completed his plastic surgery residency at the University of Michigan. In September 2000 he received the honor of presenting that school's annual William C. Grabb Lecture. After completing his plastic surgery residency, Meltzer began his practice and developed his skills further while a clinical professor of plastic surgery at Oregon Health Sciences University. There he specialized in general surgery, plastic surgery, and completed a fellowship in surgery for treatment of severe burn injuries.

Working with the chief of Plastic and Reconstructive Surgery Division at OHSU, he began training in SRS surgical techniques. In the absence of any formal training available in the area, Meltzer spent extensive time researching and interviewing pediatric urologists with experience treating children born with ambiguous genitalia, and surgeons already performing vaginoplasty surgeries such as the late Stanley Biber, MD. In 1993 he began performing vaginoplasty surgeries on a frequent basis and soon he was completing over 150 vaginoplasty cases each year. Eventually, in 1996, he opened his own private practice in Portland, Oregon. ^[2] He relocated his practice to Scottsdale, Arizona, U.S.A. in 2003.

[edit] Vaginoplasty technique

During the 1990s, Meltzer developed a vaginoplasty technique whose aspects are described in detail with a twenty-five page, step by step, photographic surgical walkthrough with detailed text captions, written by physician and sexology researcher Anne Lawrence, MD, PhD ^[3]. As described by Lawrence, Meltzer's vaginoplasty advancements include: a full thickness triangular skin flap that produces the vagina's characteristic V-shape posterior forchette; a full thickness scrotal skin graft to increase vaginal depth, which is sutured to the full thickness inverted penile skin in a serpentine pattern that helps prevent vaginal stenosis; adaptation of the Stanley Biber's Biber buttons, which are a pair of large sutures from the apex of the vaginal vault through the abdominal wall, inferior to the umbilical, that heal to form two purposefully created adhesions that help maintain vaginal depth; creation of a minimal incision through the pubococcygeus muscle to preserve a strong pelvic floor, which is kept open during surgery with a specially adapted Bookwalter ring retractor system while the vaginal cavity is dissected; creation of a sensate clitoris from a pedicle fashioned from a portion of the penile glans with its nerves and blood vessels attached; with finalization of the external vaginal appearance completed during a secondary labiaplasty surgery that is usually performed three to twelve months after the vaginoplasty. With Meltzer's technique, the full thickness scrotal skin graft also significantly increases vaginal depth. Meltzer's technique employs a fully sensate portion of the penile glans, with all attached nerves and arteries, to form the clitoris ^[4] . Meltzer's vaginoplasty techniques also reduces the blood loss during surgery to the extent that transfusion is rarely required. The intact pelvic floor maintained by Meltzer's technique, creating only a small incision through the pubococcygeus muscle portion of the levitor ani muscle complex, is visible in surgical result photographs where the vulva is shown with the labia minora held apart. The pelvic floor opening is held open during the dissection portion of the vaginoplasty surgery by a specially modified, Bookwalter ring retractor system, and other retractors. ^[5] Meltzer's vaginoplasty patients must dilate their newly created vagina after surgery. However, a significant aspect of the early post-operative dilation process, is patient stretching of the muscular pubococcygeus around the vaginal introitus. Meltzer is also one of a very few vaginoplasty and metoidioplasty surgeons who accepts HIV-positive patients. ^[6]

As an adjunct to his vaginoplasty technique, Meltzer's unique technique for refining the vagina's external appearance (the vulva), called labiaplasty, employs an inverted Y-plasty incision and suturing method that creates a hood over the sensate clitoris, and leaves only a single mid-line incision scar at the top of the vagina's vulva. Labiaplasty procedures performed by other surgeons leave at least two or more visible incision scars at the vulva's superior forchette. ^[7] While performing labiaplasty surgery Meltzer also creates scalloped edges on the newly formed labia minora with a series of sutures on the labial margins that crimp the labia as they heal. ^[8]

[edit] Other surgeries

Meltzer is equally notable for having performed numerous Cricothyroid Approximation surgeries in Portland, Oregon during the late 1990s. Cricothyroid Approximation surgery attempts to raise vocal pitch by surgically modifying the cricoid and thyroid cartilages with sutures that pull and tighten them in relationship to the surrounding muscles that control vocal pitch in the largynx.^[9] The intent of Cricothyroid Approximation is to assist patients unable to raise their vocal pitch through voice training. Recently improved voice training methods, and more readily available voice coaches, have been able to achieve similar, and often better results with vocal training alone, and without inherant vocal surgery risks, largely eliminating the demand for Cricothyroid Approximation.

Meltzer is also one of just a few U.S. surgeons who frequently performs facial feminization surgery (FFS).^[10] FFS is craniofacial surgery which involves multiple surgical procedures that together can dramatically change and feminize facial appearance. Often primary FFS surgery is comprised of several osteotomy procedures (bony cuts) on the chin (genioplasty), jaw (mandibular curvature osteotomy), glabella (middle forehead) (cranioplasty), outer eyebrow bones (supralateral orbital rim contouring), and nose (rhinoplasty) are combined during a single surgery day lasting 8-12 hours. After three to twelve months, the bony FFS procedures are sometimes followed by an additional surgery that combines various soft tissue procedures which together finalize facial feminization.

In addition, Meltzer is the only surgeon worldwide, who currently performs all of the following procedures: vaginoplasty, metoidioplasty, and facial feminization surgery, as well as the other reconstructive and plastic surgeries that comprise his practice. Meltzer also performs various other surgeries, including reconstruction of severed limbs, scar revision surgeries for burn patients and others who have various kinds of large scars caused by traumas, accidents, as well as more familiar plastic surgical procedures such as breast augmentation.