Making Them Whole

Dr. John Borkowski helps patients align their bodies with the person they are inside. Borkowski, who performs gender affirming surgeries, has established his reputation as an expert in female-to-male (FTM) and male-to-female (MTF) procedures, and says he’s “never seen happier patients.”

In a soft-spoken voice that exudes empathy and compassion for the hundreds of people seeking to align their physical appearance with their true gender through gender affirming surgery, Dr. Borkowski, part of Middlesex Health’s Transgender Program team of physicians, reflects on the plight of the transgender patients that have come to him for help – the majority of whom are FTM “tops surgery” cases.

“I believe males wishing to be reassigned as females undergo more psychological trauma than do females transforming to males,” he says. “Therefore, I think this is the reason we see more FTM patients. It’s a serious issue.” He says that gender dysphoria (a state of unease or generalized dissatisfaction because of a difference between sex assigned at birth and gender identity) is often associated with anxiety, depression, higher rates of substance abuse and other negative issues.

Possibly, another reason for the disparity in the number of MTF and FTM cases may be the health insurance industry’s refusal to recognize the need for breast augmentation surgery when it comes to MTF procedures. Dr. Borkowski deems this industry practice “absolutely discriminatory.”

“Although I’ve not had any problems with Connecticut-based insurance companies covering mastectomies for FTM patients, chest augmentation surgery for MTF patients, costing thousands of dollars, must be paid out of pocket,” he says, adding that “implants alone cost $1,000 each.”

Despite this disparity, he’s seen positive emotional changes in the makeup of patients seeking gender reassignment.

“Decades ago, when I started these procedures, patients who came to me were much older—some in their 40s, 50s and even 60s—and they were definitely traumatized following years of psychological abuse,” he says. “Today’s patients are in much better shape emotionally, now that gender reassignment is more accepted. We’re treating a younger population—many in their 20’s—who don’t have to go through decades of trauma as in the past. Post-operatively, they are the happiest patients I’ve ever seen.”

Although all of his patients are resolved to undergo top surgery, most must first go through a series of psychological evaluations involving a spectrum of specialists. This process can take a year or more before gender affirming surgery takes place. He recommends that his patients first be seen by other specialists, such as Kathryn Tierney, an endocrinologist and hormone therapy specialist who serves as the medical director of Middlesex Health’s transgender program.

“I will not operate on patients before they’ve had some counseling because the decision they’ve made is irreversible and they must know this up front,” he says.

Middlesex Health wants all of its patients to have a full understanding of procedures. As such, many transgender patients see various providers before undergoing surgery, and their health team can include mental health specialists.

Most patients are first seen by a primary care physician, a psychiatrist or a psychologist, a licensed social worker who specializes in gender identity, and an endocrine specialist.

This process can delay surgery by at least one year after the start of hormone therapy, and sometimes two years after a patient first undergoes their mental health evaluation. “Once surgical procedures begin, the amount of time needed to complete a case varies,” Dr. Borkowski says, “depending on the number of plastic surgeries the patient desires, including feminization or masculinization of the face.”

“They [patients] will tell me what they want done. For the most part, FTM want top surgery done — very few want bottom surgery — so that they may express their gender identity in a public way that conforms to how they feel inside,” he says. “For example, FTM patients may wish to go to a beach and at least wear a T-shirt [as opposed to going topless], thereby hiding the significant scaring associated with FTM top surgery. Despite scaring, no patient has ever expressed regret over their decision. Psychologically, they just want to get through this and they’re happy when it’s over.”

Following surgery, Dr. Borkowski sees patients once a week until their condition has stabilized. After that, he sees them quarterly for a year, which is about how long it takes for their post-op status to normalize. The average short-term recovery is three to four weeks before the patient returns to full activities.

The difference between a mastectomy for a cancer patient and one for an FTM patient is significant.

“Contrary to cancer patients, when we perform top surgery on an FTM patient we leave some breast tissue behind because we have to contour the chest in order to guarantee that the same amount of tissue remains above, to the side, and below the breasts. We save the nipple and the areola by taking them off as a graft and reducing them so they match the size of a male areola,” he explains. Lining up nipples, which he terms “the most difficult part,” is a process in which everyone gets a say.

“Nurses and even the anesthesiologist get to cite their opinion as to whether the chest looks contoured,” he says. “Repositioning nipples is tricky. We don’t want them to be too close, too far apart or too low or high.”

Patients are made aware that they will not regain any sensation in their nipples once replacement takes place, due to the necessity of cutting all sensory nerves, he says.

Currently, only chestchest surgery is performed at Middlesex Health, but that may change as the health system’s transgender program continues to grow.

“Genital manipulation entails a very complex series of procedures,” Dr. Borkowski explains, adding that when Middlesex gets a bottom surgeon, patients will also be seen by a urologist (following an orchiectomy, or the removal of testicles), as well as by gynecologists and psychologists.

Penile construction for FTM cases, often called a “free flap” procedure, is perhaps the most complex of all reassignment surgery, he says. It requires surgeons to reconnect a piece of tissue containing arteries, blood vessels and sometimes nerves in order to form a phallus. Following this process, a penile implant may be performed during a second or third stage operation, thereby enabling the penis to function normally. And while FTM genital reconstruction is a much more complex than the reverse, the outcome is better than it used to be, according to Dr. Borkowski.

“In male to female surgery you can use penile skin to create a vagina and testicles to create the labia. But in the opposite case, there’s nothing to work with to create the entire phallus. Usually we use skin from the leg, hip, or side of the chest — wherever we can get an artery or vein to make a decent looking phallus,” he says. “It’s not a walk in the park. It’s definitely an uncomfortable to moderately painful operation.”

In addition to chest surgery, “we may do some facial rework, too, which involves trimming off excess cartilage to the Adam’s apple (for MTF patients) so that the apple is smoother and less prominent.” This procedure is not to be confused with surgery on the vocal cords, which Dr. Borkowski does not perform, enabling males to acquire a more feminine voice. “The process of MTF voice changing is something an ear, nose and throat doctor may get into later on, if the patient wishes” he says.

The effects of testosterone on females are something the doctor calls “pretty amazing.”

“For most of them, you can’t tell they were ever female…they look like good-looking guys.” Testosterone creates increased body hair and muscle mass and an increased number of red blood cells. In some cases, there is a redistribution of fat from the breasts, waist and thighs to the abdominal area. Most develop acne during the pre-op hormone therapy stage.

Summarizing his experience with transgender patients, Dr. Borkowski calls them “the most benevolent human beings I’ve ever worked with.”

“Once I understood what these patients were going through, I didn’t hesitate to perform gender reassignment surgery,” he says.”