Your interest in the FtM phalloplasty procedures provided by the reconstructive surgeons of the Sava Perovic Foundation is much appreciated. The Foundation is led by Dr Rados Djinovic (JIN-O-VICH), Chairman, Dr Perovic's right-hand man for most of the past decade.
Through the Foundation created a number of years ago, Professor Perovic has ensured urological surgery will continue to advance greatly in the years ahead and more people than ever will get the high quality surgical solutions to their health problems that they deserve.
Dr Djinovic also leads the Sava Perovic Foundation Surgical Team. He is taking Perovic techniques, teachings, procedures and surgical philosophy to the next level in the decades ahead. In the middle of the second quarter of 2010, surgical results or not as good as in the past — they are better than ever. The crowning achievement of Sava Perovic was Dr Rados P Djinovic.
Written evaluations or answers from Dr Djinovic about any matter ALWAYS take 1-15 days, and sometimes longer.
All the patients of the Sava Perovic Foundation Surgical Team enjoy an outstanding rate of successful surgeries and an equally impressive lack of complications in addition to the best permanent surgical results available anywhere. However, only about 5% of our surgical procedures are related to MtF or FtM transsexuals and transgender sex change.
We must now share out time more equitably with ALL patients because we have more patients and more people need our help than ever before. Priority will be given to patients who have done all they can do to prepare for the surgery they want and have read everything relevant that we have published about it. This page proactively answers all questions about these particular surgical procedures so your only remaining questions should be:
- are you a suitable candidate?
- when can you get the surgery?
- exactly how much will it cost you?
The case manager is happy to promptly provide answers to any questions NOT already answered here or from any of the pages to which we have provided links here. Read the information we have already provided before asking any questions. All inquiries will get answers. All questions will be answered eventually. But patients we can help fastest and easiest because they have done all they can to help themselves will be put in the fast lane. We will attend to everyone else as soon as possible.
Gender reassignment surgery (SRS) by Dr Djinovic is dependent on the referral of mental health professionals to the surgeon. The surgeon only executes what has been approved as appropriate by mental health professionals who have diagnosed and documented your case.
The Sava Perovic Foundation adheres to the Standards of Care for Gender Identity Disorders of the Professional Association for Transgender Health (WPATH) which was originally know as the Harry Benjamin International Gender Dysphoria Association.
The chapters relevant to the letters of psychiatric approval are 4, 9, and 12. You can read the Gender Identity Disorders Standards of Care here.
If you are at the beginning of your transition, our adherence to the Standards of Care for Gender Identity Disorders means you need to locate two local doctors who can advise you. For hormonal treatment, it would need to be a endocrinologist experienced with gender reassignment.
For the psychiatric approval, it would need to be a psychiatrist experienced with gender disorders and another highly qualified mental health professional, not necessarily a psychiatrist, to confirm the psychiatrist's diagnosis. These professionals help guide you prepare mentally and emotionally for SRS and microsurgical free flap phalloplasty or metoidioplasty.
When the mental health professionals have documented your pre-operative transition from female to male and approve the next step of surgery, you can THEN make your appointment to get surgery from the Sava Perovic Foundation Surgical Team by sending us digital copies of the signed letter(s) on the official letterhead stationary of the doctors or mental health professional(s) showing you are prepared and the surgery is right for you.
Hand deliver the original versions of the letter(s) to Dr Djinovic when you come to Belgrade for phalloplasty surgery. Do not mail them or send them by courier. Do not give them to us until you come to Belgrade for actual surgery.
Cost depends on the exact surgery package you need. Getting all SRS from Dr Djinovic at the same time reduces:
- total surgical time;
- total recovery time;
- number of times under anesthesia;
- amount of time under anesthesia;
- total risk;
- total cost, particularly transport costs; and
- total transition time — 7 hours instead of months or years.
The Sava Perovic Foundation Surgical Team are the world's leading FtM SRS surgeons. Dr Djinovic can complete the transition from female to male in one surgery, including: 1) trans-vaginal hysterectomy (no visible scars); 2) oophorectomy; 3) vaginectomy; 4) metoidioplasty; and 5) scrotoplasty, including testicular prosthesis, in seven hours of surgery. Read about Perovic Metoidioplasty in detail here.
This package of surgeries requires 3-5 days recovery in hospital with 7-10 days total time in Belgrade. A patient can drive a vehicle after about seven days, return to work in 10-14 days, play sports after approximately 14 days and have non-penetrative sex after 30 days.
“Urethral advancement” is only a preparation for Perovic Total Phalloplasty surgery but is an important standard component of Perovic Metoidioplasty. A number of patients get metoidioplasty and, as shown in the video below, years later decide that Total Phalloplasty is more appropriate for their evolving personal life.
The main differences between Perovic Metoidioplasty and Perovic Total Phalloplasty surgery is:
- the size of the resulting neophallus;
- the ability to have sexual intercourse;
- the need for MLD donor site grafting;
- the need to prepare the donor sites thoroughly before surgery;
- Total Phalloplasty surgery Stage One costs about 37% more than Metoidioplasty;
- Total Phalloplasty surgery has three stages.
A Perovic Total Phalloplasty surgery neophallus can be up to 7 inches (18 cm) long with a circumference up to 5.9 inches (15 cm) — significantly longer than the national average penis size of natal males of any country in the world:
- France – 16 cm (6.3")
- Italy | Russia 15 cm (5.9")
- Mexico – 14.9 cm (5.87")
- Germany – 14.4 cm (5.7")
- Spain – 13.6 cm (5.4")
- Japan – 13 cm (5.11")
- USA – 12.9 cm (5.07") [African Americans + 1 cm, Native Americans a bit less]
- Saudi Arabia – 12.4 cm (4.9")
- India – 10.1 cm (4")
- Korea – 9.6 cm (3.8")
With a penile prosthesis implant (Stage Three), a Total Phalloplasty surgery neophallus can be used for penetrative sexual intercourse as often and as long as desired. Stage Two urethroplasty gives the penis fire hose point-and-shoot capability which is much more than merely the ability to urinate standing.
Both Perovic Metoidioplasty and Perovic Total Phalloplasty FtM bottom surgery retain the ability to have orgasms. Both enable you to urinate standing.
The musculocutaneous latissimus dorsi (MLD) donor site must be professionally massaged for AT LEAST 1-2 months or more before surgery. Download an iPOD version of the MLD massage video here. Or watch a Flash version of the training video online here.
The Sava Perovic Foundation Surgical Team can perform: 1) vaginectomy; 2) trans-vaginal hysterectomy; 3) oophorectomy; 4) urethral advancement; and 5) scrotoplasty (including testicular implants) followed one week later by Total Phalloplasty Stage One — all during the same single visit to Serbia.
The first gender reassignment surgery session takes six hours with 5-7 days hospital stay. The second surgical session takes 9-11 hours and requires seven days hospital stay. The total length of time in Belgrade is two weeks. A patient can walk unaided after 2-3 days and can drive and work after two weeks.
FtM Mastectomy for small breasts takes two hours in surgery, requires that you stay three days in hospital and you need to stay in Belgrade a total of five days. A mastectomy for large breasts takes 3-4 hours of surgery, you would stay three days in hospital and the entire visit to Belgrade would be five days.
The available FtM lower surgery packages centered on Total Phalloplasty Stage One are:
- A] 1) Total Phalloplasty Stage One + 2) scrotoplasty, including testicular implants, + NO Step One of Stage Two urethroplasty
- B] 1) Total Phalloplasty Stage One + 2) Step One of Stage Two urethroplasty
- C] 1) vaginectomy + 2) Total Phalloplasty Stage One + NO Step One of Stage Two urethroplasty
- D] 1) vaginectomy + 2) scrotoplasty, including testicular implants, + 3) Total Phalloplasty Stage One + NO Step One of Stage Two urethroplasty
- E] 1) vaginectomy + 2) urethral advancement + 3) scrotoplasty, including testicular implants, + 4) Total Phalloplasty Stage One + 5) Step One of Stage Two urethroplasty
- F] 1) vaginectomy + 2) trans-vaginal hysterectomy + 3) oophorectomy + 4) urethral advancement + 5) scrotoplasty, including testicular implants, + 6) Total Phalloplasty Stage One + 7) Step One of Stage Two urethroplasty
- G] 1) vaginectomy + 2) urethral advancement + 3) scrotoplasty with implantation of testicular prostheses: Dr Djinovic says “This is NOT ADVISABLE. It can result in difficulty voiding if the implants are placed near the temporary urethral meatus. Scrotoplasty should be done later.” In other words, this FtM bottom surgery can be a surgical package and has a specific package price but should be done over two visits to Belgrade. Patients who request this combination of surgeries are usually on a very tight budget. Carefully calculate whether the additional trip to Belgrade still enables this to make good economic sense.
Appropriate Body Mass Index (BMI) is an important factor affecting the viability of the neophallus and a person's suitability for Total Phalloplasty. Your BMI must be in the “normal” range or close to it in order to be appropriately prepared for Total Phalloplasty surgery Stage One. Check your BMI here. (see additional info below added June 1st, 2010).
About 7% of patients experience some complication with Total Phalloplasty surgery Stage One, all of which are naturally occurring. If minor surgical intervention is needed, it can be done when the patient returns to Belgrade for the next stage.
This procedure has a 100% success rate. However, one Australian patient suffered partial flap necrosis in mid-2008 due to a unique vascular drainage problem of his graft tissue.
He got corrective surgery in mid-2009 and subsequently wrote to the Sava Perovic Foundation saying: "I am very, very happy and very impressed with the result and appearance of my new penis. Your team is obviously gifted with this kind of surgery ... I am very appreciative of both Professor Perovic and Dr Djinovic for giving me the opportunity to redo the phalloplasty again, especially with waiving all of the fees associated with the recent surgery."
The Sava Perovic Foundation Surgical Team always does such revision surgery without fee.
Dr Djinovic is now able to identify this rare condition immediately upon removing the MLD flap. If this is encountered:
- the blood circulatory system of the flap will be enhanced;
- the flap will be returned to it's location at the donor site for six weeks or longer for improvement of its vascularity (flap autonomization); and the
- surgery will be postponed to a later date when the patient's body has improved the blood supply within the donor tissue.
Three months or more after Stage One, Total Phalloplasty surgery Stage Two (Urethroplasty) takes 3-4 hours of surgery. You must stay 2-3 nights in hospital and 5-7 days total time in Belgrade.
Three months or more after Stage Two, Total Phalloplasty Stage Three (Penile Prosthesis Implantation) takes three hours of surgery, requires you to stay 2-3 nights in the medical facility and 5-7 days total time in Belgrade.
Cost of the penile implant prosthesis is NOT included in the surgical fee because it varies according to brand, model, type and size that the patient chooses. Penile implant prices are set by the manufacturers, not the surgeons, and vary country-by-country. And, the cost of the prosthesis is paid directly to the manufacturer, not the Sava Perovic Foundation.
There is no maximum amount of time you can wait to between Total Phalloplasty surgery Stage 1 & 2 or Stage 2 & 3 but the minimum is 90 days between each.
Stages Two and Three are optional but you must decide your plan before starting Stage One. There is no limit on how long you wait after each stage before you get the next.
The two most recent Total Phalloplasty patients who just competed Stage Three and completed all stages together said: “I believe my friend and I have the best, functioning, aesthetically pleasing phalluses after any kind of surgery on the planet, and potentially in other galaxies as well.” [Both men are married so you can image how thrilled their wives must be as well.]
The 3-component, AMS 700 CX with MS pump inflatable penile implant with the InhibiZone Antibiotic Surface Treatment which impregnates antibiotics into the tissue-contacting surfaces of the penile prosthesis is recommended by Dr Djinovic but the LGX | Ultrex is not. Information from the manufacturer is available here.
The recommended AMS Ambicor (2-component penile implants) is the penis implant Dr Djinovic would choose for fixing erectile dysfunction if he ever developed it. It costs about 23% less than any of the 700 series AMS penile implant prosthesis models.
Semi-rigid (malleable) AMS 650TM and 600M TM AMS penile implants cost a quarter of the price of inflatable implants.
The semi-rigid Promedon Tube implant of Argentina costs about 38% less than AMS semi-rigid implants and is also highly recommended. An independent study of (natal male) patients using the Promedon Tube reported:
- Successful sexual intercourse: 90.4%
- Prosthetic infection: 0%
- Non-specific pain (subsided spontaneously, no intervention): 24%
- Prosthesis too short complaint: 32.5%
- Retarded ejaculation: 10%
- Unsatisfactory penis appearance complaint: 9.6%
- Crural cross-perforation: 4%
- Hematomas: 1.6%
- Penile hypothesia [reduced sensation] (subsided spontaneously, no intervention): 0.8%
In some Stage 3 cases, there is no option and a semi-rigid implant is medically indicated and must be used first. After a period of time it can be replaced with an inflatable one.
During the past four decades, Dr Perovic developed many secret “tips and tricks” while doing more than 20,000 operations. Those “tips and tricks” used by Dr Djinovic mean:
- complications are extremely rare;
- the ones that occur are very minor;
- patients get aesthetically pleasing surgical results;
- surgical results are extremely functional.
Visits to Belgrade by patients are very well organized and streamlined. The fees of the Sava Perovic Foundation are package prices that include everything except the cost of your hotel and airfare, extra food not provided by the hospital, and any activities not related to the surgery. Patients are picked up at the airport by the Foundation's driver and taken back to the airport when it is time to return home. There is no charge for the medical facility and, in many cases, particularly most forms of phalloplasty, it is possible to stay at the medical facility the entire visit. A companion can also stay at the facility for Euros 50 per day. Hotels nearby cost Euros 50 to 60 per night.
Dr Djinovic's Foundation Team that performs all surgeries includes:
- Dr Marko Milosavljevic;
- Dr Nikola Stanojevic; and
- Dr Vlada Pesic.
The Sava Perovic Foundation Surgical Team handles emergencies often and regularly. They are accustomed to a heavy schedule of long and complex surgeries. Dr Djinovic doesn't allow a backlog of surgeries to accumulate so there is no “waiting list”.
Request your phalloplasty surgery on the date you most prefer and Dr Djinovic will make it on the closest available date. Due to the current heavy load of surgeries, the doctors sometimes do surgery seven days per week and until late at night. A number of patients are not getting their first choice of a date so we suggest you propose a Plan A and a Plan B.
Dr Djinovic's most current schedule is available by clicking here.
If you want to move forward:
- let us know when you would prefer to have your surgery performed;
- submit your medical history (optional but advisable — and if you experience any error, you can use the "Go back one page" button of your browser, add any missing date, and resubmit with a new security code without losing all your form data);
- send as email attachments digital copies of your required psychiatric approval letters as specified by the Harry Benjamin (WPATH) Standards of Care to which Professor Perovic adheres, particularly chapters 4, 9, and 12.
- send as an email attachment a digital copy of a medical certificate from your endocrinologist documenting your hormonal therapy;
- all patients must have HIV, Hepatitis B & Hepatitis C tests. The results can be sent in advance as an email attachment or brought by hand. Tests can be done in Belgrade but are not included in price & cost Euros 50. HIV+ or Hepatitis C positive results disqualify a person from elective surgeries.
- if you are a nationality that Serbia requires to have a visa to visit Belgrade, the Sava Perovic Foundation can issue you an invitation letter for the Serbian Embassy where you apply for the visa.
A physical exam and consultation in Belgrade is also an option. Dr Djinovic does not charge for a consultation for patients traveling from afar (outside the Balkan region). However, it may not be necessary to fly to Belgrade for only a consultation if enough information and photos are provided to enable a long-distance evaluation. A consultation does not oblige a person to get any surgery.
We strongly recommend you read this comprehensive article about the risks and complications of any surgery to supplement your research about the specifics of the procedure you are considering.
In mid-2010, a number of patients who plan to get Total Phalloplasty have asked Dr Djinovic to allow them to get surgery with inappropriately high BMI. Although the tone of his comments may seem like there is a lot of flexibility in this regard, in fact, he very strongly advises patients to have “normal” BMI before getting surgery.
Dr Djinovic said:
- there are many, many advantages for a patient having BMI in the ‘normal’ range;
- his advice for a patient to have “normal” BMI is never for the benefit or convenience of the surgeons whatsoever;
- surgery is the same for the surgeon whether a patient is ‘overweight’ or ‘normal’ weight;
- ‘overweight’ category BMI patients always have complications as a result of Total Phalloplasty, in addition to the fact that ‘overweight’ BMI increases risk of becoming ill with chronic problems such as:
- high blood pressure (hypertension),
- Type 2 diabetes,
- dyslipidemia (high total cholesterol or high levels of triglycerides)
- coronary heart disease,
- stroke,
- liver and gallbladder disease,
- sleep apnea and respiratory problems,
- osteoarthritis (a degeneration of cartilage and its underlying bone within a joint),
- cancer (endometrial, breast, and colon), and
- urological problems (abnormal menses, infertility).
- the resulting neophallus of an ‘overweight’ category BMI patient is likely to be to overly large in girth (circumference) which may make it difficult to have sexual intercourse with any current or future partner;
- an overly large neophallus because the patient's BMI was ‘overweight’ at Stage One also makes Stage Two urethroplasty more difficult and complicated;
- appropriate, ‘normal’ category BMI, results in less scarring and easier donor site closure;
- patients who choose to ignore his medical recommendation regarding their weight can still possibly get surgery if they are at the lower end of the ‘overweight’ BMI range but Dr Djinovic still thinks it's not advisable (your choice, your body, your health);
- for your lifelong benefit, the surgeon recommends you have ‘normal’ classification BMI when getting Total Phalloplasty Stage One.
- On 20 July 2010, Dr Djinovic added: “Regarding a person's weight, he should have BMI close to normal in order to have successful phalloplasty.”
The National Health Service of the UK has a very precise BMI calculator.
The BMI classifications are:
- Underweight = 18.5 or less
- Normal weight = 18.5 to 24.9
- Overweight = 25 to 29.9
- Obesity Class 1 = 30 to 34.99
- Obesity Class 2 = 35 to 39.99
- Morbid Obesity = 40 or greater
Sava Perovic Foundation surgical fees are paid in Euros cash directly to Dr Djinovic only when you actually go to Belgrade and only for the surgery you are getting during that visit. The Foundation has no policy of down payments or advance payments.
An electronic bank-to-bank money transfer (T/T) is sometimes a possible alternative payment method for the bulk of a large payment, such as for Total Phalloplasty Package “F”. However, the Foundation still asks patients to bring at least Euros 4000 cash. Payment by wire transfer should be sent at least a week in advance so the doctor can find time to check it's arrival in our bank before surgery. Dr Djinovic has little time to check incoming financial transactions because of his very full schedule of surgeries.
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