Patients' Guide to Pre-Operative Hair Removal for Phalloplasty

Pre-operative hair removal is considered a medical necessity for some types of Phalloplasty. There's a lot to learn about hair removal before starting treatment, and the more you know the more likely you are to hit your hair removal goal before surgery. This guide addresses the critical aspects of hair removal as it relates to Phalloplasty and offers tips to help you get the most out of your treatment.

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Hair growth in the urethra may contribute to higher risk of urethral and bladder complications, such as blockage, fistula, urethral urine retention, post-void dribbling and infection.¹ For this reason, surgeons performing Phalloplasty with urethral extension require pre-operative hair removal from any portion of skin that will be used to construct the urethra.

"Hair serves as a filter through the new urethra. The urine is obviously full of waste. It has all kinds of stuff that eventually as it basically filters through this hair sieve, forms calcifications. Then it becomes an obstructive complication." — Dr. Ellie Zara Ley, Exclusively Inclusive Podcast

How Much of a Problem Is Hair In the Urethra?

Many Phalloplasty patients have some hair regrowth in the neourethra and most patients are unaffected by urethral hair. And, urinary obstruction from urethral hair can happen despite thorough pre-operative hair removal. A 2019 study¹⁵ from the Amsterdam team concluded that laser hair removal reduces hair growth, but that hair still grew in the new urethra. They also found that hair in the urethra didn't cause urinary voiding complaints among their patients.

"The fine hair of forearm may be aesthetically displeasing when on the shaft but does not cause stones and tends to cause fewer of the issues typically caused when pubic hair-bearing skin (from scrotal inlays) was used to line the urinary tract." — Dr. Lawrence J. Gottlieb¹⁴

Pre-operative hair removal is also done for cosmetic reasons. For example, the area of the donor site that will be used for the glans of the penis should be made hair-free. While some hair growth on the penile shaft is natural in cis gender men, many Phalloplasty patients would prefer to have a hair-free shaft or at least less hair than what their donor site presents with.

Trans people seeking hair removal before Phalloplasty have three treatment options: Electrolysis, Laser Hair Removal, or a combination of both.

Electrolysis vs. Laser Hair Removal

Electrolysis is the process of electric epilation that is approved by the US FDA for "permanent hair removal." There are three electrology modalities: galvanic, themolysis and blend (galvanic and thermolysis combined.) Read about the differences here. A benefit of electrolysis is that unlike laser hair removal its effectiveness does not depend on hair color. Electrology sessions are usually 1-2 hours long.

Laser Hair Removal (LHR) reduces the number of hairs by damaging the follicle's hair bulb versus targeting the entire follicle as electrolysis does. LHR is a more recent innovation, with the first laser used for hair removal in 1960. LHR is approved by the US FDA for "permanent hair reduction." As LHR targets hair pigment, it achieves its best results when used to remove dark hair from light skin. It's not successful at treating red, grey, white and blonde colored hair. A benefit of LHR over electrolysis is that a larger area can be treated in a much shorter time, which also means that it's usually cheaper in the long run than electrolysis. LHR sessions are usually 15-30 minutes long.

Permanent Results? Not So Fast.

With electrolysis, "hair reductions up to 90% have been reported; however the treatment efficacy is highly variable and operator- and modality-dependent, with regrowth ranging from 15-50%."²

It's also important to note that electrolysis does not prevent the activation of new follicles that were not previously active at the time of treatment. This means that it's possible for new hair to grow in an area that was treated with electrolysis. This is significant because Testosterone activates new hair follicles. Thus, patients who have not been on Testosterone for very long may be more susceptible to hair regrowth following surgery.

Several studies concluded that LHR "demonstrated the longest hair-free period for removal of unwanted hair."³ Furthermore, a review of 30 controlled trials also concluded that LHR is more effective than electrolysis. On the other hand, the American Academy of Dermatology pulls no punches and doesn't say if hair regrows after LHR, but when it regrows:

After finishing the treatments, most patients do not see any hair on the treated skin for several months or even years. When the hair regrows, there tends to be less of it. The hairs also tend to be finer and lighter in color. ⁴

So, Which Is Better?

According to a 2016 study about LHR for gender reassignment surgery: ⁵

Alexandrite-LHR provides higher clearance rates than electrolysis (74% vs. 35%, respectively) 6 months following treatment, is 60 times faster and less painful, and requires fewer treatment sessions.

Electrolysis may be cheaper per session, but many hours may be required to treat each area of hair; in contrast, LHR will treat the entire area for hair removal during each session with faster procedure times, low occurrence of side effects, and fewer needed sessions.

Reliance on [electrolysis] has persisted in public and professional transgender health care forums, despite the absence of evidence-based clinical guidelines or peer reviewed data to support favoring electrolysis over LHR.

The shift towards LHR as a superior method of hair removal suggests that it should also be the treatment of choice prior to [Phalloplasty].

This makes LHR sound very impressive but fails to take into account the patients' hair and skin color. In the end, the choice is quite personal. For some people, electrolysis will be the right choice, while others will be better served by LHR or a combination of electrolysis and LHR.

LHR machines use different types of lasers and you will want to research the machines locally available to you to find the one you're best suited to. For example, those with darker skin should be treated with machines that use longer wavelength lasers.⁷ Read about different laser types here.

Planning For Hair Removal – How Long Will It Take?

The length of time to complete hair removal before Phalloplasty is variable, based on the donor site being used, the density of hair, and the hair and skin color.

Your surgeon will provide guidance regarding the location and dimensions of the donor graft site that needs to be hair-free. At your consultation, ask your surgeon to outline the donor site on your skin using a marker. A template image may also be provided. (You can view hair removal templates for RFF and ALT Phalloplasty here and here.) These images are examples only. Surgeons use different techniques so it's important to get guidance from your Surgeon before you start hair removal.

With ALT Phalloplasty, the exact location and dimensions of the donor site are less predictable.⁸ Some surgeons have their patients get a CT scan prior to commencing hair removal which can help to more precisely determine this. (The CT scan also visualizes the amount of subcutaneous fat under the skin and the vascularity of the flap.)

Understanding the Hair Growth Cycle

Hair grows in cycles and it's important to understand this cycle because hair removal is only effective during the active growth phase of the cycle. The length of the hair growth cycle is different for the forearm and thigh:⁹

Donor Site	Active Growth (Anagen)	Transitional (Celogen)	Resting (Telogen)	Total Cycle
Forearm	4-6 weeks	2-3 weeks	16 weeks (4 months)	18-25 weeks (4.5-6.25 months)
Thigh	4-6 weeks	3-6 weeks	24 weeks (6 months)	31-36 weeks (7.75-9 months)

When you start hair removal, about 25% of the hair follicles will be in the active stage, while others will be in the transitional and resting phases. Only the hairs in the active phase will be affected by electrolysis or LHR, which is why you need to have multiple treatments spaced out by the length of time equivalent to the length of the active growth phase.

The donor site should be prepared for two full growth cycles, ideally followed by the length of time equivalent to one active growth phases to monitor for regrowth. According to the table above, that's 9-12.5 months of treatment for RFF and 15.5-18 months for ALT, plus the time to monitor for regrowth.

Sara Thomas, an electrologist who has worked with patients in the UK for over 20 years, states that at least 9 months of treatment is required for Phalloplasty.¹⁰ In a press release, Chris Hart at Cristianos Laser Clinic states that hair removal can take in the region of 12 months and advises patients to plan well in advance.

These lengths of time are somewhat contradicted in Phalloplasty studies:^{11 12}

"Hair removal via laser therapy or electrolysis begins four to six months prior to surgery."

"The European Society for Laser Dermatology recommends three to eight [laser hair removal] treatments, and the American Academy of Dermatology states that most patients need between two to six treatments. Treatments, which may each take up to 30 minutes, should be spaced at least 6 weeks apart to allow for hair cycling. Our experience with [Phalloplasty] is that it is best to wait 3 months after the last planned hair removal treatment before proceeding with surgery, in order to confirm that no further hair regrowth will occur."

Because of the hair growth cycle, simply throwing money at hair removal to fit in more sessions before your surgery will not necessarily speed up the process.

Financing Hair Removal

While some insurance plans in the US pay for pre-operative hair removal, many people have to pay out of pocket for treatments. The cost of hair removal is determined by a number of factors and is therefore difficult to estimate, but plan on spending somewhere between $1000-$2500.

Because electrolysis is more expensive, you can save money by starting with LHR to thin out a large area quickly before moving on to electrolysis.

For those with insurance that will cover hair removal, have your provider obtain CPT Codes from your surgeon. Note that there are different codes for hair removal depending on the donor site. You may have more success getting a reimbursement for hair removal costs versus upfront converage. Save your receipts!

In the UK, the NHS will cover up to 8 sessions of electrolysis and LHR, but only for the portion of the donor site to be used for the creation of the urethra.

Post-Operative Hair Removal

Hair removal on the area of the donor site that will be used for the construction of the urethra must be done pre-operatively. Trans-urethral laser hair removal is possible but very difficult to perform. Urethral chemical epilation cream has also been used to treat post-operative hair growth in the urethra, but these are solutions for post-operative complications related to hair growth and are not relied on as standard treatment.

Hair removal for aesthetic reasons can be done after surgery. This lowers pre-operative preparation and expenses, can be less painful (before sensation returns), and can more precisely target the areas where hair removal is desired. However, keep in mind that not all hair removal professionals will work on genitals, and that scarring can make hair removal less effective. It's also unclear how hair removal might affect your new organ or penile implant; ask your surgeon before proceeding.

Final Hair Removal Tips

• Before starting with hair removal, get confirmation from your surgeon regarding the exact location and dimensions of the area to be made hair-free.
  
• If your surgeon outlines the area to be made hair-free during your consult, take several photos for reference so that you can ensure the correct area is being targeted with your treatments.
  
• Going on holiday? If you're getting LHR you must avoid sun on your donor site for 3-6 weeks before and after each treatment because tanning limits the efficacy of LHR.
  
• Minoxidil is contraindicated for hair removal.
  
• Despite what you might read online, meladine and carbon dye do not make LHR more effective.
  
• Electrolysis and LHR feels a bit like getting a tattoo. Most will not require any pain medication but if you are concerned about pain, you can apply a topical anesthetic like Tetracaine or EMLA cream before your hair removal sessions. With LHR, pain will decrease with each session, as there is less pigment to target.
• LHR cannot be done over tattoos.
• If you have very dark skin and are pursuing LHR, a patch test is advised: "A small area is lasered at different energy levels to determine the right level for effective [hair] removal without burning your skin. The zone between effective level and burn is very narrow with very dark skin."¹³

Looking for an electrologist in the USA? Find one here.

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Footnotes

1. Zhang WR, Garrett GL, Arron ST, Garcia MM. Laser hair removal for genital gender affirming surgery. Translational Andrology and Urology. 2016;5(3):381-387.
2. Zhang et. al.
3. Zhang et. al.
4. Laser hair removal: FAQs. American Academy of Dermatology.
5. Zhang et. al.
6. American Academy of Dermatology.
7. Zhang et. al.
8. Zhang et. al.
9. Hair Loss: The Science of Hair. WebMD.
10. Transsexual and Transgender. Gender Transitions.
11. Shane D. Morrison, MD, MS; Marcelina G. Perez; Cayden K. Carter; Curtis N. Crane, MD. Pre- and Post-operative Care With Associated Intra-operative Techniques for Phalloplasty in Female-to-male Patients.
Urol Nurs. 2015;35(3):134-138.
12. Zhang et. al.
13. Laser Hair Removal For Dark Skin Is Possible, As Long As You Follow These 4 Guidelines. Bustle.
14. Gottlieb LJ. Radial Forearm. Clin Plast Surg. 2018 Jul;45(3):391-398.
15. Pigot GLS, Belboukhaddaoui S, Bouman MB, Meuleman EJH, de Boer EM, Buncamper ME, Ronkes B, Mullender MG, Nieuwenhuijzen JA. Effectiveness of Preoperative Depilation of the Urethral Donor Site for Phalloplasty: Neourethral Hair Growth and its Effects on Voiding. Eur Urol Focus. 2019 Apr 22. pii: S2405-4569(19)30121-X.

 

Last updated: 07/01/22