Center for Gender Affirmation

Dr. Ramineni – “For too long, many transgender patients have been happy just to simply receive care.“Good enough” is no longer acceptable in my opinion – the bar must be raised.We must deliver top notch individualized care that improves on the current status quo and takes gender affirming surgery to the highest quality standard”

“Saw Dr. Ramineni for FtM top surgery. He’s amazing – friendly, doesn’t talk down to you but also doesn’t speak medical jargon over your head.He’s extremely communicative and answers questions via email within 24 hours. His staff is ALSO amazing – responsive and helpful and just all around great. Everyone I dealt with throughout this process has been terrific.A note on pronouns, titles and names – not once was I misgendered by Dr. Ramineni or his staff OR the hospital staff during the surgery experience. NOT A SINGLE TIME.Cannot recommend him highly enough. Six stars out of five.”

Surgical and Non–Surgical Services

Top Surgery

Mastectomy

Top surgery is a very common procedure – we performed over 140 top surgeries and the vast majority were able to be covered by insurance.  Unlike some surgeons, I do not require liposuction as part of the procedure (totally optional in all cases and not needed in most patients)

Double incision – A “standard” double incision technique remove breast tissue and excess skin, resizes and repositions the areolar and nipple to a proportionate cis-chest. The procedure does leave a permanent scar which in most cases improves with time (although never disappears completely).  I generally follow the normal contours of the pectoralis muscle for a very aesthetic curve that mimics the natural shape of the chest.  If you look at a body builder, the incision is never a straight line.  This also minimizes the likelihood of dog ears, revisions – very rare in my practice. There is a nipple “bolster” placed to help the nipple graft heal and a drain on each side – these are both removed within a week.  There is no showering/getting the nipple wet for 2 weeks after which you can start most activities (strenuous exercises such as push-ups, bench pressing, yoga and full unrestricted activity is ok at 4 weeks.  Most patients take 2 weeks off from school/work, however it depends on your occupation. Patients that have desk jobs, are in school or are able to work from home, may be able to return to work in as little as a week, while patients with jobs that require heavy lifting may need to wait 3 weeks. The surgery takes just over an hour and has an extremely high satisfaction rate.  It is an outpatient surgery (go home same day) and we will provide you with a post-operative vest that you will need to wear for approximately 2 weeks after surgery – then no more binding ever again!!!

Periareolar Technique/Keyhole Mastectomy

These techniques are more individualized depending on the desire for nipple sensation (always some tradeoff for flatness) and the preoperative size of the nipple and areola.  Good candidates for minimal incision procedures require small breasts, good skin tone and minimal extra skin.  Depending on the areolar and nipple size, this can sometimes require just an incision from 3 to 9 o’clock, or an incision all the way around the nipple or a periareolar (around the nipple) incision plus a standard double incision line for patients that want to maintain nipple sensation.  We can perform a nipple reduction at the same time and sometimes an areolar reduction at the same time.  In some cases, this may need to be done as a 2-stage procedure for optimal results.  We also offer Renuvion JPlasma for patients who are “borderline” peri candidates that can be used to tighten skin to a certain degree without excising it (considered experimental by insurance and not covered). We will provide a vest post operatively and it is generally an easier recovery than a double incision and you can shower within 48-72 hours.

Breast Augmentation

Breast augmentation is a very straightforward technique that uses a small incision (just over an inch) to place breast implants. The surgery takes under an hour and you go home the same day.  Pain is minimal and recovery is relatively easy – some patients are back to work within a day or two. We use top of the line cohesive gel/gummy bear implants that minimize the possibility of rippling.   There are special considerations in transfemale patients that may not be recognized by surgeons who don’t perform this procedure on a regular basis.  Nipple positioning tends to be lower and more lateral than in a standard cis-female augmentation and oftentimes the inframammary fold (fold under the breast) is high and has to be lowered and released to center the implant and minimize the chance of a “double bubble” deformity (where there appear to be 2 folds on the lower portion of the breast).  A soft bra (without underwire) is worn for several weeks after the procedure. 

Facial Feminization

This is a very individualized treatment that is different for each patient.  While some patients are born with features that will not cause them to be misgendered/not cause dysphoria, other patients are not as lucky.  Some patients may just need two areas addressed and some patients require multiple procedures to achieve their goals.  The specific areas that are most commonly addressed are:

Brow Bone Reduction – A masculine forehead tends to be more rounded, has a prominent brow ridge and has eyebrows that are at or below the brow ridge.  This can also make the eyes look smaller.  Brow bone contouring is addressed through either an incision at the front of the hairline (leaves a visible scar, but necessary if hairline procedures are performed) or through a coronal incision (back further in the hairline and hidden).  The bone is reduced by either just burring in patients that do not have a frontal sinus, have minimal “bossing” or have a thick front wall of the sinus.  For patients that have a higher degree of prominence of the brow bone, removing the front wall of the sinuses and performing a “set back” with mini plates and screws may be needed to achieve an optimal result. The goal is to create a more vertical feminine forehead, wider appearing eyes, elevation of the brows, and flattening of the prominent brow ridge.

Hairline Advancement – Masculine foreheads tend to have a longer forehead with a “M shape” with widow’s peaks. This can be more dramatic in some patients and can be accentuated or downplayed depending on hairstyle.  The typical feminine forehead has a rounded shape and is shorter. The forehead can be modified at the same time as a brow bone reduction with the same incision (at the front of the hairline).  This can leave a visible scar that can oftentimes be covered with either hairstyling or hair transplantation in the future.

Tracheal Shaving – this is a procedure to remove cartilage and reduce the Adams Apple which is a prominent secondary sexual characteristic that develops in puberty in some patients.  Although this can be done in the office procedure room, I strongly prefer to perform this procedure in the operating room under anesthesia to be able to directly visualize the vocal cords with an endoscope. This allows me to remove more cartilage and minimize the risk of vocal cord injury which can lead to a hoarse voice and voice changes.  Procedures done in the office make it impossible to visualize the vocal cords and less cartilage is generally removed to avoid vocal cord damage – since the cords can’t be visualized without a scope.  This procedure takes about 45 minutes and has a very quick recovery and almost no downtime.

Chin Reduction – Male chins tend to have a W shape, are wider and have more vertical and horizontal height.  Female chins tend to have a V shape and are narrower and have less width.  The surgery is performed to eliminate the W shape and to narrow the chin.  Depending on the chin size, either simple burring/shaving of the mandible or a “T” osteotomy is performed.  The T shaped bone removal removes height and width of the chin and small plates and screws are used to fixate the new smaller chin.  This is done through in incision inside the mouth that heals quickly.  Downtime mostly consists of a few days of diet restriction.

Mandibular angle reduction – A square jaw can be a masculine feature, or in thin patients who have naturally angled features may still be a feminine feature that creates a “model-like” appearance.  This can be done as an individual treatment or in combination with a chin reduction surgery.  It is performed through an incision inside the mouth and either a burr or an angled saw is used to shave this down and round out the lateral face.

Cheek enhancement – Cheek enhancement for more prominent cheekbones can be performed with either implants, fillers or fat grafting depending on the degree and patient desires. Implants are placed through the mouth and filler/fat is injected though a needle into the face directly

Lip Lift and Augmentation – a long upper lip often indicates age and is more masculine.  A short upper lip rejuvenates the face, can create a lip “pout” and feminizes the lip.  This is performed with a small incision at the base of the nostrils to hide the scar.  The lips can also be augmented with fat or filler to produce fuller lips.

Rhinoplasty – Each nose is different, and each patients’ goals are different in regard to the nose.  More narrow noses, smaller nasal tips and a smaller overall nose does tend to feminize the nose.  Specific maneuvers can include infracturing the nasal bones to narrow the upper nose.  Thinning the tip by decreasing the cartilage size is the most commonly requested procedure.  In some cases, the lower nose is very wide and removing a portion of the nostril can be performed.

“Staff is Awesome. Dr. Ramineni is equally Awesome!  Everyone is genuinely focused on delivering and amazing experience as well as an amazing outcome!! I’m about a month post-op and I’m healing well, and the results are phenomenal!! A million thanks to everyone at West End and Dr. Ramineni and his team!!”

Bottom Surgery

Vaginoplasty

Vaginoplasty surgery is a major surgery that we generally perform as a surgical team in conjunction with the Urology service (Dr. Kelly Chiles).  The surgery takes approximately 4 hours and the hospital stay ranges between 2-7 days (averaging 4-5 days).  In most cases, insurance will cover this procedure. We use a penile inversion technique and can perform either minimal depth or a full depth technique depending on patient preference and ability to commit to dilation.  With this procedure a new vagina is created with labia majora, labia minora, a clitoris for sexual pleasure, and a shortened urethra.  Most patients are able to achieve orgasm once healing is complete.  Hair removal with electrolysis is preferred, but by no means required. In surgery, we can thin the graft and individually burn the hair follicles. The vast majority of our patients opt not to have hair removal before surgery due to either financial considerations (not often covered by insurance) or the desire not to have to wait over a year to have the procedure (hair removal is painful, takes multiple treatment sessions and can take 1-2 years to achieve total clearance of the hair follicles).  This surgery requires a longer time commitment due to the complexity of the surgery and full recovery can take up to 3 months (although most patients should be able to return to work and full activities in 4-6 weeks).  Minor touch up surgeries are common for small aesthetic improvements that cannot be performed at the same time as the initial operation due to technical considerations and are done as an outpatient surgery with a much lower downtime.

Metoidioplasty

This procedure can be performed in patients who have had increased size of the clitoris due to the effects of testosterone.  It can be performed as a simple release or more commonly creating a new urethra and rerouting the urine flow to ideally be able to urinate standing up. At the same time, the vagina can be removed and closed off and the labia major can be used to create a new scrotum (testicle implants can be placed later).  Hysterectomy can be performed by the gynecology service at the same time or preferably, be done prior to metoidioplasty.

Revisional surgery/Corrective Surgery

Unfortunately, due to limitations in care, lack of standardization/quality assurance, and financial concerns, or had procedures done out of desperation, we often see patients who have had poor outcomes from surgeries done elsewhere in the United States or Internationally.  Oftentimes procedures were done by someone who was did not have the requisite training or in some cases was performing illegal procedures.  These can range from poor surgical outcomes, procedures that have been complicated by infection, etc, “botched” operations, free silicone injections into the buttock, thighs, face, breasts or elsewhere, etc.  In cases like these, we create individualized plans to help correct deformities and are often able to correct some or all of the damage/deformity.

Body Contouring Procedures

There are multiple procedures that can be used to shape the body to accentuate or decrease certain areas to achieve either a more masculine or feminine shape.  Options include “manscaping” liposuction to narrow the hips, waist, lateral chest fat and sometimes abdominal or inner thigh fat, body implants including hip, buttock (Brazilian Buttock Lift) and pectoral implants, fat transfer to the hips or buttocks or standard liposuction to create an hourglass figure are all possibilities.

Other procedures – general cosmetic surgery, fillers, Botox, injections for hair electrolysis

We currently are not offering phalloplasty or colovaginoplasty procedures or hair transplantation

“Dr. Ramineni was wonderful from start to finish. It is a rare thing to find such a skilled surgeon with such a fantastic bed side manner”

Payment options

In addition to standard payment options, we also work with financing companies such as Care Credit.

Insurances Accepted:

       With insurance companies becoming more progressive, many gender affirmation procedures can be covered by insurance. In fact, we are able to get the majority of our patient’s surgeries covered by insurance. 

        Our staff is knowledgeable about getting insurance coverage for procedures.  In some procedures such as mastectomy, vaginoplasty, metoidioplasty and revisional surgery we are very often able to obtain insurance coverage, other procedures are sometime covered – breast augmentation, tracheal shaves, and facial feminization. Some procedures are virtually never covered – body contouring, liposuction, and general cosmetic surgery.  Insurance plans are constantly evolving and in most cases, we can let you know at your initial consult if it will be possible to run your surgery through insurance. Available links to insurance policies are attached.

Insurer/Policies:

Care first 

https://secure.compliance360.com/Common/ViewUploadedFile.aspx?PD=PbRt%2bA78MS7QoX2A%2b0%2fNIghkihBfwvxFkKH3jOiyp7nuDjYh2R2j7YAg7vNYLb%2bSIDfeoGoWuEer4sCmesK1FLyFqtWxfJukugQim1qrMV%2bN6FQH9GIbqg2GUcFoEypxazl4z2f8fZJ52rwgJYzHDeF1dKhOrKXaiDFZO%2f0MPz1ef8AwF8PfRWPmTzBDzxYUCsXRB7SKad8%2brDYI6szEymDzvoCWjNwosx7IAE06qtJJBWMD6P0bCnGVrPx8QXKUODRCbBFuY%2b475pfVFhho3Tt4ybipzNw5

Blue Cross Federal – page 67, 68

https://media.fepblue.org/-/media/PDFs/Brochures/2019_SO_BO_SBP_Brochure.pdf

United Health Care

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medicaid-comm-plan/gender-dysphoria-treatment-cs.pdf

Aetna

http://www.aetna.com/cpb/medical/data/600_699/0615.html

Cigna

https://cignaforhcp.cigna.com/public/content/pdf/coveragePolicies/medical/mm_0266_coveragepositioncriteria_gender_reassignment_surgery.pdf

Humana

https://dctm.humana.com/Mentor/Web/v.aspx?objectID=0900092982828a03

Tricare

Surgery not covered

Blue Cross/Blue Shield PPOs – individual plans vary in coverage – refer to the local policy

Amerihealth – DC Medicaid MCO

https://www.amerihealthcaritasdc.com/pdf/provider/resources/clinical/policies/170302v_gender-dysphoria.pdf

GEHA

https://www.geha.com/~/media/Files/Documents/Health-Documents/coverage-policies/Gender-Reassignment.pdf?la=en

Medicare – no standardized policy

Anthem/Highmark/Premara/other Blue Cross/Blue Shield PPO plans

Any insurance with out of network benefits

Even if you have an insurance that we are not in network for, many insurances are willing to allow us to see and treat you if they don’t have a provider in network who can adequately provide care.  This is especially true for more complex procedures for bottom surgery. *We use in network facilities and anesthesiologists for insurance surgeries

Multiple procedure discounts

We understand that while some patients may just desire one procedure, other patients may desire multiple procedures to feel complete and avoid being misgendered. We offer multiple procedure discounts to make this more cost effective.  We offer a 10% discount for the second procedure and 20% off all subsequent procedures performed at the same time.

Price List

Mastectomy – Double incision – $3500 (1.5 hours)

Mastectomy – Periareolar – $3000 (1.5 hours)

Mastectomy – Periareolar plus J plasma skin tightening – $5000 (includes disposable handpiece)

Brow bone reduction (plus hairline advancement if desired) – $5500 (2 hours)

Rhinoplasty (tip) – $4000 (1.5 hours)

Rhinoplasty full – $5000 (2 hours)

Facial fat grafting – $1500 (can be done in procedure room – $500 facility fee only)

Lip lift – $1500 (can be done in procedure room – $500 facility fee only)

Tracheal shave – $3000 (1 hour), if done in office $2500 total

Chin reduction T osteotomy with plating- $4000 (1.5 hours)

Chin reduction – burring only – $3000 (1 hour)

Mandibular angle reduction – $2500 (1 hour)

Chin and angle combined reduction – $5000 burring, $5500 with osteotomy (2/2.5 hours)

Vaginoplasty (full depth)- $19,500 (will need at least 1 day in hospital – $800/night), (4 hours)

Vaginoplasty (minimal depth) – $15,000 (will need 1 day in hospital – $800/night), (3 hours)

Revisional Surgery – variable

Breast augmentation – $3000, plus implants ($1700 for 2 top of the line silicone implants) (1 hr)

Hip implants – $3000 (1 hour)

Buttock implants $4000, plus implants ($2000), 1.5 hours

Brazilian Buttock lift – $6500 (includes 360 lipo for fat harvest) – (2.5 hours)

Metoidioplasty – simple release – $5000, includes vaginectomy and scrotoplasty (2.5 hours)

Metoidioplasty – with urethral lengthening – $8000 (3 hours)

Orchiectomy – $3500 (1 hour)

  • Operating room/Anesthesia fees start at $1300 for the first hour and are approximately $700 for each additional hour and are subject to change.  Each surgery varies in terms of operative length depending on the patient.

“Dr. Ramineni was wonderful from start to finish. It is a rare thing to find such a skilled surgeon with such a fantastic bed side manner”

Letters

Therapist letters are always required for any procedure that will be submitted for insurance prior authorization (with the exception of revisions).  Ideally, if you can bring your letter to the appointment we can submit your procedure to insurance for prior authorization sooner. It is best to refer to your individual insurance plan (see links) to determine if a service is covered and their requirements.  In general bottom surgery will require 2 letters with at least 1 from a doctorate or masters level provider (psychologist, psychiatrist) and all other surgeries mostly require 1 letter from any qualified mental health provider (some insurances do require 2 letters for top surgery)

With insurance companies becoming more progressive, many procedures can be covered by insurance. In fact, the majority of gender affirming surgeries performed at West End Plastic Surgery are able to be covered by insurance.  Our insurance staff is knowledgeable about getting insurance coverage for procedures.  In some procedures such as mastectomy, vaginoplasty, metoidioplasty and revisional surgery we are very often able to to obtain insurance coverage, other procedures are sometime covered – breast augmentation, tracheal shaves, and facial feminization. Some procedures are virtually never covered – body contouring, liposuction, and general cosmetic surgery.  Insurance plans are constantly evolving and, in most cases, we can let you know at your initial consult if it will be possible to run your surgery through insurance.

Care Team

Dr. Ramineni – Surgeon

Katie Leemaster – Physician assistant – Patient Liaison for clinical questions

Chavonne Ligon – Scheduling/Surgical Coordinator/Patient Liaison for surgical logistics

Jackie Santos – Patient Liaison for non-clinical questions, office scheduling, forms, etc.

Ginia Price – Insurance questions, prior authorizations

Dr. Kelly Chiles – Urology (co-surgeon for bottom surgery)

We can also provide referrals (if needed) for fertility preservation, therapists, hysterectomy, electrolysis, phalloplasty

Out of Town Patients

We recommend that you stay in the DC area for 1-2 weeks after surgical procedures or be able to commute back to DC (depending on the procedure).  We have discounted rates at the Fairmont Hotel (ask for West End Plastic Surgery) if a hotel stay is needed. We can also give you contact information for home nursing care if desired.

Our office can be contacted at 202-785-4187 to schedule a consultation.  Although our operative schedule usually has 100-150 patients scheduled, we are usually able to figure out a surgical date on the date of your consult (if you wish to schedule).  We are generally booked out about 2 months in advance, but there are sometimes openings sooner due to patients that have needed to reschedule/cancel.  Certain times of year are much busier and may get filled 6 months in advance (the weeks around Christmas/New Years, Thanksgiving week, spring break and early summer vacation times.). 

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