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Just three anecdotes that I've noted now that I've done a few hundred pellet implants that might be useful to other doctors who are also doing them. As always they aren't a peer reviewed study, just the observations of a guy who has done literally hundreds of pellet implantations on transgender people over the past two years.
- Putting them in the upper outer butt as is recommended is dumb. I've had zero issues with numbing people up at the underbutt crease and then angling the numbing and also the trocar upwards into the gluteal fat to avoid the deeper structures. It results in a far better cosmetic outcome, and at reimplantation, the scar is nearly invisible 6-12 months later. I ask patients now if they have any tingling going down the leg after the numbing is in (indicating a sciatic branch is nearby). If that ever happens, I would switch sites, but this seems a fairly safe way to ensure proper placement as well as a superior outcome. I have had zero complaints from my trans porn stars and some have even done shoots within a week of implantation with only a dab of makeup covering the incisional mark. It seems equally safe but with a superior cosmetic result. Like I said, I've done hundreds now without ever having even one patient report leg parasthesias at the numbing stage (or any post complications of the like). Just choose the spot in the underbutt (I could not find an actual anatomical term for the line where the badonkadonk forms a skin crease due to the prominence of the gluteal curve as it meets the posterior thigh so I'm sticking with underbutt until someone corrects me) where it hangs over the most (like an under-breast incision for an implant) and numb there, angle your needle upwards and then numb all the way deep from there. I use a 3 inch long spinal tap-ish 27g needle for this purpose. The needle bends with pressure so you're able to actually curve the deposition of the numbing agent which I do to sort of fan it out into the tissue over the whole distribution of where the trochar goes. I then make an incision with an 11 blade sized to the exact size of the trochar (3.5mm or 5.5mm) so the incision is as small as possible. I push the blade in to the "hilt" and so the incision is always perfectly sized and as short as possible for the implant size. I use 0.25% marcaine without Epi, as bleeding is minimal and people get 6-12 hours of numbing from it so they can fly home after without much pain. I will be switching soon to ropivacaine which lasts longer and has less complications/motor block, but it wasn't available generic for awhile due to backorder and the brand form was expensive as hell. I plan to test some mixtures of bup/rop on myself and see if a blend of the two results in superior duration due to differences in protein binding/lipophilicity as I couldn't find a good answer in the literature for hybridizing them. The goal simply being to make sure someone gets home and picks up their antibiotics and pain meds if needed before the drug wears off. Rarely do the estrogen pellets cause any significant pain post implantation as their quantity is less and the size is much smaller, but the testosterone implants are like pushing 10 extra strength tylenol where the estrogen is usually about 5 tictacs. I do not suture this closed, I use surgical glue to seal it. After closed with surgical glue, I place 2 steri-strips across the lesion and then one parallel to the lesion to further anchor it, and then I coat those in surgical glue as well as the surrounding skin to transfer any shearing forces away from the incision to prevent wound dehisence. I then after that place a bandaid over the steri strips which is either a kitten, an avocado cat, a rainbow heart, yoshi, mario, peach, bowser or toad. This last step is very important. (it also prevents the partially dried glue from adhering to the patients clothes as they've spent 15 minutes on a table with their ass exposed to the world and generally they like to get dressed quickly so this allows them to get right up, dress, and not feel as awkward as I feel every moment I'm alive.
- Once the trochar is placed and you begin to drive the pellets into the space, push until you feel the "wall". This is the first pellet running into the tissue. If you continue to push at this point, you will feel pellets crush and subsequently the volume to surface area ratio of these pellets change resulting in higher levels for less time. The purpose of the big pellets is to last longer, and so crushing one into powder or even breaking it into 4 pieces results in basically 4x 12.5mg pellets instead of 1x 50mg pellet. More surface area = faster degradation and higher levels. The trick is to push until you feel that resistance, then back the trochar back about 1cm, push gently until they drop in, and if you feel another resistance, back out again 1cm and push again. The trochar sits about 5cm deep, and so in this way, you can place them safely into the gluteal fat without damaging them, which results in a lower level that lasts much longer (which is the purpose of pellets). Pellets are effectively like getting a super long lasting E2 injection, with a big slow ramp up and ramp down. The more intact and large the pellets are, the longer and smoother the curve. Since I started this technique a little over a year ago, I've had more and more people lasting well beyond the average 6-8 months. Today I replaced pellets on a patient that I did in october 2020, setting the office record of 13 months off one 300mg (6x 50mg) implantation with literally perfect levels the entire time. It was only once she approached dropping below 200 that I replaced them. SHBG remained under 125 the whole time.
- Shot patients should do two more shots after the implantation. It seems to be the best compromise between not accidentally overdosing someone by continuing shots too long after implantation but also not crashing someone out by stopping them on pellet day (or 5 days before pellet day). Pill patients should take them for about 2 weeks after implantation. The first week at their full dose, the second at half their usual dose. This isn't perfect (as everyone metabolizes pellets differently due to 2 factors, one, the rate at which their immune system chips away at the foreign object, and two, the rate at which they degrade the released estradiol. But this general rule seems to result in the least complaints of feeling crashed out or OD'd.
As always, this is just the personal experience of some rambling idiot who clearly doesn't know shit, is a quack, and hasn't published anything ever so why even bother listening or trying to improve this technology right?
Somedays I write shit like this, and know that some trans person is going to hand it to their doctor and ask them to read it, and the doctor is going to see "Dr. Powers" on it, and throw it in the trash. So I'm not sure why I bother, but I hope it helps someone get better care somewhere.
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