gender reassignment surgery before and after ftm

9 inspiring photos to help you transition from female to male

Gender affirmation surgery can be an incredibly freeing and life-changing decision. But it’s also understandable if the thought of going under the knife makes you anxious. Like any major surgery, there are risks of complications, scarring, and infection. And depending on the kind of surgery you get, you can experience changes in sexual satisfaction and sensation in certain areas.

But for the majority of trans people who opt for  surgery , the benefits outweigh the risks and disadvantages. For one, researchers have reported that there are long-term  mental health benefits to gender affirmation surgery. Many trans people have said that the anxiety and depression they’ve had due to gender dysphoria lessens over time, and they begin to feel more comfortable, confident, and at home in their bodies. Plus, the complication rate for female to male gender affirmation surgery is relatively low at 5.8%.

If you’re still apprehensive about gender-affirming surgery and its effects on your sexual and physical health, perhaps seeing success stories from trans men who have gone through it all may help assuage your worries. So here are a few “female to male” transition photos to inspire and affirm so you can have a little bit of a preview of what to expect on your own transition.

Related:  Transgender People Are Less Healthy Than Cis People, Here’s Why

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9 Transition Photos That Prove That It Does Get Better

Before we jump into our list of inspiring images, we’d like to point out that transitioning is different for everyone. Some people may feel that gender-affirming surgery is integral to the improvement of their mental health. Others may not even see surgery and hormone therapy (HRT) as a necessary step in their transition journey. It’s totally fine either way, as long as you’re happy!

And for those who do undergo some type of procedure, remember that individual results vary. The photos included in this list are meant to inspire and affirm but are in no way the gold standard of what a trans person post-surgery is supposed to look like. In fact, there is no standard! All bodies are unique, valid, and beautiful either way.

1. Jamie Raines

Jamie Raines is an English YouTuber who often talks about his experiences as a trans man in his vlogs. Over the course of six years, Jamie documented his transition journey, taking viewers along for the ride as he experienced all the physical and psychological changes of undergoing HRT, top surgery, and metoidioplasty – a type of surgery done to create a “new penis” out of tissues taken from the clitoris.

Unlike a phalloplasty, which is a complicated procedure that involves lengthening one’s urethra and a skin graft from one’s forearm for penile construction, metoidioplasty surgery has a lower risk of urological complications and a faster healing time. Raines also underwent scrotoplasty, which is a form of lower surgery done to create a scrotum.

Check out these side-by-side photos of Jamie six months after their top surgery and eight years post-op.

  View this post on Instagram   A post shared by Jamie Raines (@jammi.dodger)

2. Chella Man

Chella Man is a deaf, trans-masculine, Chinese-Jewish artist who, like Jamie, spent several years documenting his transition journey and sharing his experiences with HRT and top surgery. Chella has spoken up about having to be “his own representation” as he had a hard time finding someone else in the media who looked like him.

Last year, Chella shared a video of himself during his first top surgery consultation next to a video of himself one month post-op and eight months on testosterone. In the caption, he writes about the evident changes the procedures have done not only to his appearance but to his confidence as well.

“Today, one month post-op and 8 months on testosterone, I stand with ease, welcoming the reflection I now see,” Chella writes. “My days of dysphoria have finally passed. I am free.”

  View this post on Instagram   A post shared by Chella Man (@chellaman)

3. Aiden Mann

Aiden Mann’s journey proves that gender-affirming surgery won’t always be a walk in the park and that for some trans folk, revisions are just part of the process. Through Instagram and TikTok, Aiden has been open about his struggles with the results of his subcutaneous mastectomy (a procedure involving the removal of the tissues in one’s breasts). He’s had to undergo multiple visits to his surgeon and several revisions, particularly because of the way his nipple scars heal.

But still, Aiden persisted and seems happier than ever!

  View this post on Instagram   A post shared by Aiden Michael Mann 🏳️‍⚧️ (@aiden_m365)

4. Emmett Preciado

Emmett Preciado is a trans man and actor who has appeared on shows like Freeform’s  Good Trouble  and ABC’s  The Good Doctor . On his website bio, Emmett shares that he wrestled with his identity a lot growing up. When he hit puberty, he wore “layers and hoodies to cover his chest” because he didn’t want the girls in his class to see that he was becoming like them.

Today, you can see Emmett bare his chest proudly on Instagram. Proof positive that it does get better!

  View this post on Instagram   A post shared by Emmett Preciado (@emmettpreciado)

5. Jake Graf

While some trans men opt to get a total hysterectomy, others don’t or hold off on the surgery to have kids in the future. Such is the case of actor, writer, director, and activist Jake Graf, who had a baby with his wife via surrogacy. Jake paused his HRT for six months and had his eggs harvested at a fertility clinic.

Jake’s story is a great reminder that undergoing gender-affirming surgery and taking HRT doesn’t mean you have to give up your dreams of raising a family. Check out this precious photo of Jake with his wife Hannah and their adorable baby girl.

  View this post on Instagram   A post shared by Jake Graf (@jake_graf5)

6. Skyler Jay

Like Aiden, trans activist and community organizer Skyler Jay has been open about the issues he’s had with his health following his surgery. After Skyler underwent a double mastectomy to remove his breast tissue, he went through surgery complications, revisions, and far more months of healing than expected, but he says he wouldn’t have it any other way.

“I knew I had to go through my pain to have that top surgery”, says Skyler in a video to promote his non-profit,  Aadya Rising . “I would do it again if that’s what it meant to get me to where I’m at right now”.

Today, Skyler is living his best life. Skyler’s story and even footage of his top surgery were featured in a groundbreaking episode of Netflix’s  Queer Eye .

  View this post on Instagram   A post shared by Skyler Jay (@trans.ginger)

7. Laith Ashley

Laith is a model, actor, and activist who has been featured in major publications like  British GQ ,  Vogue France , and  Attitude UK . Growing up, Laith struggled with his sexual orientation and gender identity, as well as his family’s disapproval.

However, in an interview with  British GQ , Laith says that it was when he came across YouTube videos of trans people documenting their transition journeys that he realized “this is who I am”.

  View this post on Instagram   A post shared by Laith Ashley De La Cruz (@laith_ashley)

8. Aydian Dowling

Looking for some fitspiration? Check out the inspirational Aydian Dowling. He is a life and fitness coach and the creator of TRACE, an app that trans people can use to document their transition, take voice recordings, and create reminders for essential appointments and procedures. On his Instagram page, Aydian drops some helpful truth bombs about fitness, mental health, self-image, and self-confidence.

Oh, and did we mention he’s the first trans man to appear on a special edition cover of  Men’s Health  magazine?

  View this post on Instagram   A post shared by Aydian Dowling (a•den) (@alionsfear)

9. Leo Sheng

Like some of the others on this list, Leo Sheng’s top surgery recovery process hasn’t always been pretty. The activist, public speaker, and writer recently shared some photos from the early days of their recovery, where their scars and bruises were still very apparent. He also opened up about some of the “what if’s” they’ve had when ruminating on their journey, and whether it was all worth it, despite not getting the results he intended.

“Everyone’s bodies are different, which means everyone heals differently,” Leo writes. “I feel good about my chest today. I feel proud of it. I’m reminded to give past and present self some grace. I know that healed the best that it could – that I did the best I could”.

  View this post on Instagram   A post shared by Leo Sheng (@ileosheng)

Final Thoughts

Gender-affirming surgery doesn’t just change the way you look, it can change the entire trajectory of your life. And despite the possibility of complications, revisions, and the need for adjustments in one’s sexual expectations, most patients say they don’t regret having the surgery. And if these pictures are any indication, getting surgery is almost always worth it. Of course, as long as that’s what you really want to be happy and at ease in your body!

Related:  Drago Renteria Is The Father Of Deaf Queer Activism

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Metoidioplasty

Surgical Description Intended Results Related Procedures Surgical Complications Post-Operative Recovery Post-Operative Results Eligibility

Surgical Description

Metoidioplasty (meta) is a female to male gender reassignment surgery (GRS). Metoidioplasty surgeons have a high success rate for the before and after surgery results. Metoidioplasty is a highly customizable female to male surgery that allows each candidate to choose the options that best suit their needs. Because each person who chooses to have metoidioplasty is different, there is a wide range of options that candidates can discuss with their surgeon. Generally, the enlarged clitoris, which is an effect of testosterone hormone replacement therapy (HRT), is relocated upwards to create a sensate and functioning micropenis. The surrounding skin of the clitoris is removed and “released” from the pubis to give the impression of more length. This results in a circumcised appearance, although patients may opt for an uncircumcised look. The suspensory ligament may be partially divided. Labial ligaments and the urethral plate are released, which allows the penis to extend further outward. The procedure may involve the creation of a glans and scrotum by using the tissue from the labia majora or labia minora with two testicle prosthesis. Metoidioplasty generally takes 2-3 hours to complete, is less expensive, and has potentially fewer complications than  phalloplasty . The procedure may be done under conscious sedation. General anesthesia may be necessary if the patient opts for primary urethral lengthening, hysterectomy, or vaginectomy.

Intended Results

The final result is a very small, realistic-looking penis (micropenis) that is sensate and can achieve an erection. A goal of FTM metoidioplasty is to preserve the clitoral erectile tissue so that patients may achieve an erection without the assistance of an erectile prosthesis. Nearly all patients are able to achieve post-operative clitoral orgasms. Some patients may be able to use the micropenis for sexual penetration, but it is not guaranteed, as the size, shape, and erectile rigidity of the micropenis ranges by individual. Actual results are dependent upon various factors. Clitoral enlargement attributable to testosterone HRT helps to increase the size. Patients who are near their ideal body weight, who are not overweight, and who do not smoke have the highest opportunity for success. Removing the skin and fat of the mons pubis, and pulling the skin upward will improve results in most patients. This results in a curvilinear scar in the pubic area. It is usually performed as a second stage when the scrotal expanders are replaced with permanent testicular implants. The benefit of metoidioplasty is that it is non-invasive and there are little to no apparent surgical scars. Clitoral sensitivity remains intact. Recipients may undergo later genital reconstructive procedures such as phalloplasty.

Related Procedures

Pre-meta (clitoral lengthening), scrotoplasty.

• Urethral lengthening

Mons Resection

Vaginectomy.

• Testosterone HRT

The clitoris may be lengthened by severing the suspensory ligament that connects the clitoris to the pubic symphysis. A metoidioplasty that does not involve scrotoplasty and urethraplasty is called a clitoral release. The disadvantage of a clitoral release alone is that it does not allow the patient to urinate through the new micropenis. The advantage of a clitoral release performed alone is that there is a reduced risk of complications, and the enlarged clitoris is visually and functionally enhanced. Some patients may be able to use the micropenis for sexual penetration, but it is not guaranteed, as the size and shape of the micropenis ranges by individual. Pre-Meta (Clitoral Release)

The goal of scrotoplasty is to create the appearance of a scrotum. Scrotoplasty may be performed at the same time as the metoidioplasty procedure. Prior to scrotoplasty, select patients may be required to use tissue expanders in the labia majora. Tissue expanders are inflatable balloons that patients gradually expand at home. This is beneficial because it provides the surgeon with enough tissue to insert prosthetic testicles and reduces problems with the prosthetic testicles. Due to the location of the expanders, patients may need to have a friend or partner help them when inflating the balloons. Permanent prosthesis can be placed in the expanded scrotum after 3-6 months of expanding. Patients can then return home the same day. Although this requires two operations, the results are frequently better. Patients who chose not to use expanders may have to return at a later date to adjust their prosthesis so that they fall evenly (one may rise above the other due to the constricted space). Patients may be required to wait 3-6 months after urethral lengthening to have expanders or prosthesis placed.

Urethral lengthening (urethral extension)

Urethral lengthening may be performed at the same time as metoidioplasty. Mucosal tissues from the vaginal canal, mouth, or outer tissues are used to extend the urethra so that patients may urinate through the micropenis. A urethral catheter is placed for assistance in voiding during post-operative recovery.

Primary Urethral Lengthening

If a primary urethral lengthening is done with metoidioplasty, a vaginectomy must be performed at the same time. A urethral catheter is placed for assistance in voiding during post-operative recovery. Expanders or scrotal implants should not be placed when primary urethral lengthening is performed. They place pressure on the urethra that can complicate the procedure. Implants and expanders should be placed at least 3 months following urethral lengthening.

Second Stage Urethral Lengthening (Buccal Mucosa Urethral Lengthening)

In second stage urethral lengthening, patients first receive a metoidioplasty. This frequently means the mons pubis is partially removed. The urethra may be extended 3 months later by using a lining of tissue from the cheek. It is used to construct the neourethra, which is extended through the tip of the penis, allowing patients to stand to urinate. Expanders or scrotal implants should not be placed when second stage urethral lengthening is performed. They place pressure on the urethra that can complicate the procedure. Implants and expanders should be placed at least 3 months following urethral lengthening. Expanders or implants may need to be removed temporarily if they are already present. A vaginectomy must be performed at the same time if it was not done during a the prior metoidioplasty. This requires that the patient have a hysterectomy/oophorectomy if they have not already done so. Dr. Toby Meltzer uses the buccal lining (lining of the mouth) for urethral lengthening.

A mons resection is best suited for metoidioplasty patients with a prominent fat collection or loose skin over this area. Heavier patients undergoing metoidioplasty may benefit from a mons resection to further elevate the penis and scrotum. As a result, a mons resection allows the penis and scrotum to be relocated to a more forward position. It is frequently done with metoidioplasty if urethral lengthening is not simultaneously performed. Since this is a cosmetic procedure, it is rarely covered by insurance.

Mons resection is generally performed under intravaneous sedation followed by an overnight stay in the hospital. Exceptions may be made for patients who have a caregiver. An elliptically-shaped segment of skin and fatty tissue is removed. The skin is then pulled upward, which pulls the penis and scrotum forward. The procedure results in an incision that is disguised by the pubis and abdominal hair.

Post-operative Recovery

A drain is placed in the incision for 1 day following surgery to prevent fluid build-up in the region. Patients may feel numbness for a few hours until the local anesthetic wears off. Sutures will dissolve slowly over time. Bruising and swelling should subside over 2-4 weeks, with the final result appearing over 2-3 months.

Surgical Complications

Risk of complication varies by individual. Minor complications, such as a localized infection, occasionally occur. Major complications are rare.

Vaginectomy in female-to-male patients involves removal of the vaginal canal. The anterior wall of the vagina may be used to lengthen the urethra in order to enable patients to void out of the micropenis. A hysterectomy/oophorectomy must be performed at the same time as vaginectomy if the patient has not already had their female reproductive organs removed.

Hysterectomy/Oopherectomy

Visit the hysterectomy page for more information. Hysterectomy/Oopherectomy

Testosterone HRT before metoidioplasty

A surgeon may recommend that surgical candidates undergo at least one year of testosterone hormone replacement therapy before undergoing metoidioplasty. The clitoral enlargement that results from testosterone HRT provides the surgeon with more tissue in which to create a functioning micropenis. Surgeons may also recommend that candidates apply a topical testosterone, called dihydrotestosterone, to encourage clitoral growth. In addition, metoidioplasty candidates may be encouraged to use a pumping device to increase the size of the clitoris as well. Testosterone HRT

The degree of risk is impacted by the health of the recipient. It is important to have a consultation with the surgeon before undergoing the procedure so that he or she may evaluate the risks particular to the patient.

A fistula is an abnormal connection between two organs or passageways that do not connect. Urogenital fistula is the most commonly reported fistula that occurs in metoidioplasty patients. For more information about fistulas, visit  http://en.wikipedia.org/wiki/Fistula .

Urethral Stricture

Urethral stricture is a narrowing of the urethral tube that may cause painful urination or frequent urinary tract infections (UTIs). For more information about urethral stricture, visit  http://en.wikipedia.org/wiki/Urethral_stricture .

Post-Operative Recovery

Recovery for patients undergoing metoidioplasty only.

Patients should prepare to take a minimum 7 day leave of absence from work if they are having metoidioplasty without urethral lengthening, vaginectomy, or hysterectomy/oophorectomy. Bed rest and ice packs are recommended for a minimum of 24 hours. Patients should refrain from lifting over 10 pounds for 2 weeks. Sutures should dissolve in 2-3 weeks.

Recovery for patients undergoing metoidioplasty with urethral lengthening, vaginectomy, or hysterectomy/oophorectomy

Patients should prepare to take a minimum 14 day leave of absence from work if they are having metoidioplasty with urethral lengthening, vaginectomy, or hysterectomy/oophorectomy. Bed rest and ice packs are recommended for a minimum of 24 hours. Patients should refrain from lifting over 10 pounds for 2 weeks. Patients who opt to have a metoidioplasty and hysterectomy simultaneously should refrain from heavy lifting over 10 pounds for at least 4 weeks. Sutures should dissolve in 2-3 weeks.

Post-operative Results

Patient studies by dr. djordevic and dr. perovic in the  journal of sexual medicine, 2011: a study of 273 metoidioplasty patients between 2005-2011  [1].

The average length of the neophallus of surgical patients ranged from 4-10 centimeters.  The mean size of the neophallus in metoidioplasty performed by Dr. Djordevic was 5.7 cm. There was no significant deviation between the neophallus sizes reported in surgeries performed in an earlier 2009 study. Most patients were satisfied with the results. 100% of patients were able to achieve postoperative erection. Unlike phalloplasty, most of the metoidioplasty patients were unable to perform penetrative sex since the neophallus is too small. 96% of patients were able to urinate without difficulty while standing. A few patients experienced dribbling and spraying that later resolved without medical intervention. Less than 5% of patients experienced complications from urethroplasty. All urethroplasty complications were successfully resolved by minor surgical intervention.

2011: A Study of 167 Urethral Reconstruction in Metoidioplasty Patients between 2003-2011  [2]

Three different methods of urethral reconstruction were compared:

• 57.15% success rate
• 12.57% of patients in this group developed fistulas
• 4.79% of patients experienced urethral stricture
• 79.05% success rate
• 19.04% of patients experienced urethral stricture
• 90.47% success rate
•  8.57% of patients developed fistulas
• 4.87% of patients experienced urethral stricture.

The results indicated that the method of choice for urethroplasty occurred in group III (combined buccal mucosa graft and labia minor flap). This method resulted in a lower incidence of post surgical complications.  91% of patients were able to urinate while standing. The overall success rate for all groups was 82.64%.

2009 Publication: A Study of 82 Metoidioplasty Patients between 2002-2007  [3]

The 2009 study revealed that the average length of the neophallus ranged from 4-10 centimeters, with a mean size of 5.7 cm. All patients were able to urinate while standing, although 23 out of 82 patients experienced dribbling and spraying in the initial post-recovery phase. 2 out of 82 patients experienced urethral strictures (narrowing of the urethral tube that may cause painful urination or frequent urinary tract infections).  7 out of 82 patients developed fistulas that required a minor revisionary surgery. There were two urethral strictures and seven fistulas that required secondary minor revision. All patients retained sensation and the ability to achieve an erection. Testicle prostheses implantation was successful in all patients.

[1]   http://www.genitalsurgerybelgrade.com/ftm_surgery_detail.php?Metoidioplasty-3  (2005-2011) [2] Miroslav, Djordjevic, MD, DusanStanojevic, MD, Marta Bizic, MD, Vladimir Kojovic, MD, Alexandar Milosevic, MD. Urethral reconstruction in metoidioplasty: comparison of three different methods. WPATH Symposium. 2011 [3]  Djordjevic ML, Stanojevic D, Bizic M, Kojovic V, Majstorovic M, Vujovic S, Milosevic A, Korac G, and Perovic SV.  Metoidioplasty as a single stage sex reassignment surgery in female transsexuals: Belgrade experience.  Journal of Sexual Medicine, 2009. [First published online in 2008]

Eligibility

Most surgeons follow the WPATH Standards of Care to determine eligibility for pre-metoidioplasty. The prerequisite standards include pre-operative psychological counseling, two letters of support, hormone therapy, and at least one year living as male. Inquire with your surgeon for their specific requirements. As with all surgeries, the best candidates are individuals in stable health. Obesity and smoking are associated with an increase in adverse surgical outcomes. Patients should be at least 18 years old for optimal results. Genital growth following hormones will increase the results of the procedure. Thus, patients are encouraged to delay pre-metoidioplasty until they have been on testosterone treatment for at least 2 years. This ensures that clitoral growth attributed to HRT is at its threshold size. Some surgeons recommend that candidates “pump” before the procedure. Pumping the clitoral area increases blood flow to the organ, which increases growth beyond HRT results. Patients should be willing to accept the limitations of the surgery. The procedure results in a very small micropenis. It will likely not be large enough for penetration, although this has been disputed, as many trans men have been able to perform intercourse after they fully recover.

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Aesthetic and Functional Genital and Perineal Surgery: Male

Sex reassignment surgery in the female-to-male transsexual, stan j. monstrey.

1 Department of Plastic Surgery, Ghent University Hospital, Gent, Belgium

Peter Ceulemans

Piet hoebeke.

2 Department of Urology, Ghent University Hospital, Gent, Belgium

In female-to-male transsexuals, the operative procedures are usually performed in different stages: first the subcutaneous mastectomy which is often combined with a hysterectomy-ovarectomy (endoscopically assisted). The next operative procedure consists of the genital transformation and includes a vaginectomy, a reconstruction of the horizontal part of the urethra, a scrotoplasty and a penile reconstruction usually with a radial forearm flap (or an alternative). After about one year, penile (erection) prosthesis and testicular prostheses can be implanted when sensation has returned to the tip of the penis. The authors provide a state-of-the-art overview of the different gender reassignment surgery procedures that can be performed in a female-to-male transsexual.

Transsexual patients have the absolute conviction of being born in the wrong body and this severe identity problem results in a lot of suffering from early childhood on. Although the exact etiology of transsexualism is still not fully understood, it is most probably a result of a combination of various biological and psychological factors. As to the treatment, it is universally agreed that the only real therapeutic option consists of “adjusting the body to the mind” (or gender reassignment) because trying to “adjust the mind to the body” with psychotherapy has been shown to alleviate the severe suffering of these patients. Gender reassignment usually consists of a diagnostic phase (mostly supported by a mental health professional), followed by hormonal therapy (through an endocrinologist), a real-life experience, and at the end the gender reassignment surgery itself.

As to the criteria of readiness and eligibility for these surgical interventions, it is universally recommended to adhere to the Standards of Care (SOC) of the WPATH (World Professional association of Transgender Health) 1 . It is usually advised to stop all hormonal therapy 2 to 3 weeks preoperatively.

The two major sex reassignment surgery (SRS) interventions in the female-to-male transsexual patients that will be addressed here are (1) the subcutaneous mastectomy (SCM), often combined with a hysterectomy/ ovariectomy; and (2) the actual genital transformation consisting of vaginectomy, reconstruction of the fixed part of the urethra (if isolated, metoidioplasty), scrotoplasty and phalloplasty. At a later stage, a testicular prostheses and/or erection prosthesis can be inserted.

SUBCUTANEOUS MASTECTOMY

General principles.

Because hormonal treatment has little influence on breast size, the first (and, arguably, most important) surgery performed in the female-to-male (FTM) transsexual is the creation of a male chest by means of a SCM. This procedure allows the patient to live more easily in the male role 2 , 3 , 4 , 5 and thereby facilitates the “real-life experience,” a prerequisite for genital surgery.

The goal of the SCM in a FTM transsexual patient is to create an aesthetically pleasing male chest, which includes removal of breast tissue and excess skin, reduction and proper positioning of the nipple and areola, obliteration of the inframammary fold, and minimization of chest-wall scars. 4 , 5 Many different techniques have been described to achieve these goals and most authors agree that skin excess , not breast volume, is the factor that should determine the appropriate SCM technique. 2 , 3 , 4 , 5 Recently, the importance of the skin elasticity has also been demonstrated and it is important to realize that in this patient population, poor skin quality can be exacerbated when the patient has engaged in years of “breast binding” (Fig. 1 ). 6

(A,B) Result of long-term “breast binding.”

In the largest series to date, Monstrey et al 6 described an algorithm of five different techniques to perform an aesthetically satisfactory SCM (Fig. 2 ). Preoperative parameters to be evaluated include breast volume, degree of excess skin, nipple-areola complex (NAC) size and position, and skin elasticity.

Algorithm for choosing appropriate subcutaneous mastectomy technique.

Regardless of the technique, it is extremely important to preserve all subcutaneous fat when dissecting the glandular tissue from the flaps. This ensures thick flaps that produce a pleasing contour. Liposuction is only occasionally indicated laterally, or to attain complete symmetry at the end of the procedure. Postoperatively, a circumferential elastic bandage is placed around the chest wall and maintained for a total of 4 to 6 weeks.

The semicircular technique (Fig. 3 ) is essentially the same procedure as that described by Webster in 1946 7 for gynecomastia. It is useful for individuals with smaller breasts and elastic skin. A sufficient amount of glandular tissue should be left in situ beneath the NAC to avoid a depression. The particular advantage of this technique is the small and well-concealed scar which is confined to (the lower half of) the nipple-areola complex. The major drawback is the small window through which to work, making excision of breast tissue and hemostasis more challenging.

Semicircular technique. (A) Incisions and scar; (B) preoperative; (C) postoperative.

In cases of smaller breasts with large prominent nipples, the transareolar technique (Fig. 4 ) is used. This is similar to the procedure described by Pitanguy in 1966 8 and allows for subtotal resection and immediate reduction of the nipple. The resulting scar traverses the areola horizontally and passes around the upper aspect of the nipple.

Transareolar technique. (A,B) Incisions and scar; (C) preoperative; (D) postoperative.

The concentric circular technique (Fig. 5 ) is similar to that described by Davidson in 1979. 9 It is used for breasts with a medium-sized skin envelope (B cup), or in the case of smaller breasts with poor skin elasticity. The resulting scar will be confined to the circumference of the areola. The concentric incision can be drawn as a circle or ellipse, enabling deepithelialization of a calculated amount of skin in the vertical or horizontal direction. 4 , 5 Access is gained via an incision in the inferior aspect of the outer circle leaving a wide pedicle for the NAC. A purse-string suture is placed and set to the desired areolar diameter (usually 25–30 mm). The advantage of this technique is that it allows for reduction and/or repositioning of the areola, where required, and for the removal of excess skin.

Concentric circular technique. (A) incisions; (B) preoperative; (C) postoperative.

The extended concentric circular technique (Fig. 6 ) is similar to the concentric circular technique, but includes one or two additional triangular excisions of skin and subcutaneous tissue lateral and/ or medial. This technique is useful for correcting skin excess and wrinkling produced by large differences between the inner and outer circles. The resulting scars will be around the areola, with horizontal extensions onto the breast skin, depending on the degree of excess skin.

Extended concentric circular technique. (A) Incisions and scar; (B) preoperative preoperative; (C) postoperative.

The free nipple graft technique (Fig. 7 ) has been proposed by several authors for patients with large and ptotic breasts. 2 , 3 , 10 , 11 , 12 It consists of harvesting the NAC as a full-thickness skin graft; amputating the breast; and grafting the NAC onto its new location on the chest wall. Our preference is to place the incision horizontally 1 to 2 cm above the inframammary fold, and then to move upwards laterally below the lateral border of the pectoralis major muscle. The placement of the NAC usually corresponds to the 4th or 5th intercostal space. Clinical judgment is most important, however, and we always sit the patient up intraoperatively to check final nipple position. The advantages of the free nipple graft technique are easy chest contouring, excellent exposure and more rapid resection of tissue, as well as nipple reduction, areola resizing, and repositioning. The disadvantages are the long residual scars, NAC pigmentary and sensory changes, and the possibility of incomplete graft take.

Free nipple graft technique. (A) Incisions and scar; (B) preoperative; (C) postoperative.

Complications

Postoperative complications include hematoma (most frequent, despite drains and compression bandages), (partial) nipple necrosis, and abscess formation. This underscores the importance of achieving good hemostasis intraoperatively. Smaller hematomas and seromas can be evacuated through puncture, but for larger collections surgical evacuation is required.

Another not infrequent complication consists of skin slough of the NAC, which can be left to heal by conservative means. The exceptional cases of partial or total nipple necrosis may require a secondary nipple reconstruction. Even in the patients without complications, ~25% required an additional procedure to improve the aesthetic results. The likelihood of an additional aesthetic correction should be discussed with the patient in advance. 13 Tattoo of the areola may be performed for depigmentation.

The recommendations of the authors are summarized in their algorithm (Fig. 2 ), which clearly demonstrates that a larger skin envelope and a less elastic skin will require progressively a longer-incision technique. The FTM transsexual patients are rightfully becoming a patient population that is better informed and more demanding as to the aesthetic outcomes.

Finally, it is important to note that there have been reports of breast cancer after bilateral SCM in this population 14 , 15 , 16 because in most patients the preserved NAC and the always incomplete glandular resection leave behind tissue at risk of malignant transformation.

PHALLOPLASTY

In performing a phalloplasty for a FTM transsexual, the surgeon should reconstruct an aesthetically appealing neophallus, with erogenous and tactile sensation, which enables the patient to void while standing and have sexual intercourse like a natural male, in a one-stage procedure. 17 , 18 The reconstructive procedure should also provide a normal scrotum, be predictably reproducible without functional loss in the donor area, and leave the patient with minimal scarring or disfigurement.

Despite the multitude of flaps that have been employed and described (often as Case Reports), the radial forearm is universally considered the gold standard in penile reconstruction. 17 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28

In the largest series to date (almost 300 patients), Monstrey et al 29 recently described the technical aspects of radial forearm phalloplasty and the extent to which this technique, in their hands approximates the criteria for ideal penile reconstruction.

For the genitoperineal transformation (vaginectomy, urethral reconstruction, scrotoplasty, phalloplasty), two surgical teams operate at the same time with the patient first placed in a gynecological (lithotomy) position. In the perineal area, a urologist may perform a vaginectomy, and lengthen the urethra with mucosa between the minor labiae. The vaginectomy is a mucosal colpectomy in which the mucosal lining of the vaginal cavity is removed. After excision, a pelvic floor reconstruction is always performed to prevent possible diseases such as cystocele and rectocele. This reconstruction of the fixed part of the urethra is combined with a scrotal reconstruction by means of two transposition flaps of the greater labia resulting in a very natural looking bifid scrotum.

Simultaneously, the plastic surgeon dissects the free vascularized flap of the forearm. The creation of a phallus with a tube-in-a-tube technique is performed with the flap still attached to the forearm by its vascular pedicle (Fig. 8A ). This is commonly performed on the ulnar aspect of the skin island. A small skin flap and a skin graft are used to create a corona and simulate the glans of the penis (Fig. 8B ).

(A–D) Phallic reconstruction with the radial forearm flap: creation of a tube (urethra) within a tube (penis).

Once the urethra is lengthened and the acceptor (recipient) vessels are dissected in the groin area, the patient is put into a supine position. The free flap can be transferred to the pubic area after the urethral anastomosis: the radial artery is microsurgically connected to the common femoral artery in an end-to-side fashion and the venous anastomosis is performed between the cephalic vein and the greater saphenous vein (Fig. 8C ). One forearm nerve is connected to the ilioinguinal nerve for protective sensation and the other nerve of the arm is anastomosed to one of the dorsal clitoral nerves for erogenous sensation. The clitoris is usually denuded and buried underneath the penis, thus keeping the possibility to be stimulated during sexual intercourse with the neophallus.

In the first 50 patients of this series, the defect on the forearm was covered with full-thickness skin grafts taken from the groin area. In subsequent patients, the defect was covered with split-thickness skin grafts harvested from the medial and anterior thigh (Fig. 8D ).

All patients received a suprapubic urinary diversion postoperatively.

The patients remain in bed during a one-week postoperative period, after which the transurethral catheter is removed. At that time, the suprapubic catheter was clamped, and voiding was begun. Effective voiding might not be observed for several days. Before removal of the suprapubic catheter, a cystography with voiding urethrography was performed.

The average hospital stay for the phalloplasty procedure was 2½ weeks.

Tattooing of the glans should be performed after a 2- to 3-month period, before sensation returns to the penis.

Implantation of the testicular prostheses should be performed after 6 months, but it is typically done in combination with the implantation of a penile erection prosthesis. Before these procedures are undertaken, sensation must be returned to the tip of the penis. This usually does not occur for at least a year.

The Ideal Goals of Penile Reconstruction in FTM Surgery

What can be achieved with this radial forearm flap technique as to the ideal requisites for penile reconstruction?

A ONE-STAGE PROCEDURE

In 1993, Hage 20 stated that a complete penile reconstruction with erection prosthesis never can be performed in one single operation. Monstrey et al, 29 early in their series and to reduce the number of surgeries, performed a (sort of) all-in-one procedure that included a SCM and a complete genitoperineal transformation. However, later in their series they performed the SCM first most often in combination with a total hysterectomy and ovariectomy.

The reason for this change in protocol was that lengthy operations (>8 hours) resulted in considerable blood loss and increased operative risk. 30 Moreover, an aesthetic SCM is not to be considered as an easy operation and should not be performed “quickly” before the major phalloplasty operation.

AN AESTHETIC PHALLUS

Phallic construction has become predictable enough to refine its aesthetic goals, which includes the use of a technique that can be replicated with minimal complications. In this respect, the radial forearm flap has several advantages: the flap is thin and pliable allowing the construction of a normal sized, tube-within-a-tube penis; the flap is easy to dissect and is predictably well vascularized making it safe to perform an (aesthetic) glansplasty at the distal end of the flap. The final cosmetic outcome of a radial forearm phalloplasty is a subjective determination, but the ability of most patients to shower with other men or to go to the sauna is the usual cosmetic barometer (Fig. 9A-C ).

(A–C) Late postoperative results of radial forearm phalloplasties.

The potential aesthetic drawbacks of the radial forearm flap are the need for a rigidity prosthesis and possibly some volume loss over time.

TACTILE AND EROGENOUS SENSATION

Of the various flaps used for penile reconstruction, the radial forearm flap has the greatest sensitivity. 1 Selvaggi and Monstrey et al. always connect one antebrachial nerve to the ilioinguinal nerve for protective sensation and the other forearm nerve with one dorsal clitoral nerve. The denuded clitoris was always placed directly below the phallic shaft. Later manipulation of the neophallus allows for stimulation of the still-innervated clitoris. After one year, all patients had regained tactile sensitivity in their penis, which is an absolute requirement for safe insertion of an erection prosthesis. 31

In a long-term follow-up study on postoperative sexual and physical health, more than 80% of the patients reported improvement in sexual satisfaction and greater ease in reaching orgasm (100% in practicing postoperative FTM transsexuals). 32

VOIDING WHILE STANDING

For biological males as well as for FTM transsexuals undergoing a phalloplasty, the ability to void while standing is a high priority. 33 Unfortunately, the reported incidences of urological complications, such as urethrocutaneous fistulas, stenoses, strictures, and hairy urethras are extremely high in all series of phalloplasties, as high as 80%. 34 For this reason, certain (well-intentioned) surgeons have even stopped reconstructing a complete neo-urethra. 35 , 36

In their series of radial forearm phalloplasties, Hoebeke and Monstrey still reported a urological complication rate of 41% (119/287), but the majority of these early fistulas closed spontaneously and ultimately all patients were able to void through the newly reconstructed penis. 37 Because it is unknown how the new urethra—a 16-cm skin tube—will affect bladder function in the long term, lifelong urologic follow-up was strongly recommended for all these patients.

MINIMAL MORBIDITY

Complications following phalloplasty include the general complications attendant to any surgical intervention such as minor wound healing problems in the groin area or a few patients with a (minor) pulmonary embolism despite adequate prevention (interrupting hormonal therapy, fractioned heparin subcutaneously, elastic stockings). A vaginectomy is usually considered a particularly difficult operation with a high risk of postoperative bleeding, but in their series no major bleedings were seen. 30 Two early patients displayed symptoms of nerve compression in the lower leg, but after reducing the length of the gynecological positioning to under 2 hours, this complication never occurred again. Apart from the urinary fistulas and/or stenoses, most complications of the radial forearm phalloplasty are related to the free tissue transfer. The total flap failure in their series was very low (<1%, 2/287) despite a somewhat higher anastomotic revision rate (12% or 34/287). About 7 (3%) of the patients demonstrated some degree of skin slough or partial flap necrosis. This was more often the case in smokers, in those who insisted on a large-sized penis requiring a larger flap, and also in patients having undergone anastomotic revision.

With smoking being a significant risk factor, under our current policy, we no longer operate on patients who fail to quit smoking one year prior to their surgery.

NO FUNCTIONAL LOSS AND MINIMAL SCARRING IN THE DONOR AREA

The major drawback of the radial forearm flap has always been the unattractive donor site scar on the forearm (Fig. 10 ). Selvaggi et al conducted a long-term follow-up study 38 of 125 radial forearm phalloplasties to assess the degree of functional loss and aesthetic impairment after harvesting such a large forearm flap. An increased donor site morbidity was expected, but the early and late complications did not differ from the rates reported in the literature for the smaller flaps as used in head and neck reconstruction. 38 No major or long-term problems (such as functional limitation, nerve injury, chronic pain/edema, or cold intolerance) were identified. Finally, with regard to the aesthetic outcome of the donor site, they found that the patients were very accepting of the donor site scar, viewing it as a worthwhile trade-off for the creation of a phallus (Fig. 10 ). 38 Suprafascial flap dissection, full thickness skin grafts, and the use of dermal substitutes may contribute to a better forearm scar.

(A,B) Aspect of the donor site after a phalloplasty with a radial forearm flap.

NORMAL SCROTUM

For the FTM patient, the goal of creating natural-appearing genitals also applies to the scrotum. As the labia majora are the embryological counterpart of the scrotum, many previous scrotoplasty techniques left the hair-bearing labia majora in situ, with midline closure and prosthetic implant filling, or brought the scrotum in front of the legs using a V-Y plasty. These techniques were aesthetically unappealing and reminiscent of the female genitalia. Selvaggi in 2009 reported on a novel scrotoplasty technique, which combines a V-Y plasty with a 90-degree turning of the labial flaps resulting in an anterior transposition of labial skin (Fig. 11 ). The excellent aesthetic outcome of this male-looking (anteriorly located) scrotum, the functional advantage of fewer urological complications and the easier implantation of testicular prostheses make this the technique of choice. 39

Reconstruction of a lateral looking scrotum with two transposition flaps: (A) before and (B) after implantation of testicular prostheses.

SEXUAL INTERCOURSE

In a radial forearm phalloplasty, the insertion of erection prosthesis is required to engage in sexual intercourse. In the past, attempts have been made to use bone or cartilage, but no good long-term results are described. The rigid and semirigid prostheses seem to have a high perforation rate and therefore were never used in our patients. Hoebeke, in the largest series to date on erection prostheses after penile reconstruction, only used the hydraulic systems available for impotent men. A recent long-term follow-up study showed an explantation rate of 44% in 130 patients, mainly due to malpositioning, technical failure, or infection. Still, more than 80% of the patients were able to have normal sexual intercourse with penetration. 37 In another study, it was demonstrated that patients with an erection prosthesis were more able to attain their sexual expectations than those without prosthesis (Fig. 12 ). 32

(A,B) Phalloplasty after implantation of an erection prosthesis.

A major concern regarding erectile prostheses is long-term follow-up. These devices were developed for impotent (older) men who have a shorter life expectancy and who are sexually less active than the mostly younger FTM patients.

Alternative Phalloplasty Techniques

Metaidoioplasty.

A metoidioplasty uses the (hypertrophied) clitoris to reconstruct the microphallus in a way comparable to the correction of chordee and lengthening of a urethra in cases of severe hypospadias. Eichner 40 prefers to call this intervention “the clitoris penoid.” In metoidioplasty, the clitoral hood is lifted and the suspensory ligament of the clitoris is detached from the pubic bone, allowing the clitoris to extend out further. An embryonic urethral plate is divided from the underside of the clitoris to permit outward extension and a visible erection. Then the urethra is advanced to the tip of the new penis. The technique is very similar to the reconstruction of the horizontal part of the urethra in a normal phalloplasty procedure. During the same procedure, a scrotal reconstruction, with a transposition flap of the labia majora (as previously described) is performed combined with a vaginectomy.

FTM patients interested in this procedure should be informed preoperatively that voiding while standing cannot be guaranteed, and that sexual intercourse will not be possible (Fig. 13 ).

Results of a metoidioplasty procedure.

The major advantage of metoidioplasty is the complete lack of scarring outside the genital area. Another advantage is that its cost is substantially lower than that of phalloplasty. Complications of this procedure also include urethral obstruction and/or urethral fistula.

It is always possible to perform a regular phalloplasty (e.g., with a radial forearm flap) at a later stage, and with substantially less risk of complications and operation time.

FIBULA FLAP

There have been several reports on penile reconstruction with the fibular flap based on the peroneal artery and the peroneal vein. 27 , 41 , 42 It consists of a piece of fibula that is vascularized by its periosteal blood supply and connected through perforating (septal) vessels to an overlying skin island at the lateral site of the lower leg. The advantage of the fibular flap is that it makes sexual intercourse possible without a penile prosthesis. The disadvantages are a pointed deformity to the distal part of the penis when the extra skin can glide around the end of fibular bone, and that a permanently erected phallus is impractical.

Many authors seem to agree that the fibular osteocutaneous flap is an optimal solution for penile reconstruction in a natal male. 42

NEW SURGICAL DEVELOPMENTS: THE PERFORATOR FLAPS

Perforator flaps are considered the ultimate form of tissue transfer. Donor site morbidity is reduced to an absolute minimum, and the usually large vascular pedicles provide an additional range of motion or an easier vascular anastomosis. At present, the most promising perforator flap for penile reconstruction is the anterolateral thigh (ALT) flap. This flap is a skin flap based on a perforator from the descending branch of the lateral circumflex femoral artery, which is a branch from the femoral artery. It can be used both as a free flap 43 and as a pedicled flap 44 then avoiding the problems related to microsurgical free flap transfer. The problem related to this flap is the (usually) thick layer of subcutaneous fat making it difficult to reconstruct the urethra as a vascularized tube within a tube. This flap might be more indicated for phallic reconstruction in the so-called boys without a penis, like in cases of vesical exstrophy (Fig. 14 ). However, in the future, this flap may become an interesting alternative to the radial forearm flap, particularly as a pedicled flap. If a solution could be found for a well-vascularized urethra, use of the ALT flap could be an attractive alternative to the radial forearm phalloplasty. The donor site is less conspicuous, and secondary corrections at that site are easier to make. Other perforator flaps include the thoracodorsal perforator artery flap (TAP) and the deep inferior epigastric perforator artery flap (DIEP). The latter might be an especially good solution for FTM patients who have been pregnant in the past. Using the perforator flap as a pedicled flap can be very attractive, both financially and technically.

Penile reconstruction with a pedicled anterolateral thigh flap. (A) Preoperative and (B) postoperative results.

The Importance of a Multidisciplinary Approach

Gender reassignment, particularly reassignment surgery, requires close cooperation between the different surgical specialties. In phalloplasty, the collaboration between the plastic surgeon, the urologist, and the gynecologist is essential. 45 The actual penile reconstruction is typically performed by the plastic and reconstructive surgeon, and the contribution of the gynecologist, who performs a hysterectomy and a BSO (preferably through a minimal endoscopic access in combination with SCM), should not be underestimated.

However, in the long term, the urologist's role may be the most important for patients who have undergone penile reconstruction, especially because the complication rate is rather high, particularly with regard to the number of urinary fistulas and urinary stenoses. The urologist also reconstructs the fixed part of the urethra. He or she is likely the best choice for implantation and follow-up of the penile and/or testicular prostheses. They must also address later sequelae, including stone formation. Moreover, the surgical complexity of adding an elongated conduit (skin-tube urethra) to a biological female bladder, and the long-term effects of evacuating urine through this skin tube, demand lifelong urological follow-up.

Therefore, professionals who unite to create a gender reassignment program should be aware of the necessity of a strong alliance between the plastic surgeon, the urologist, mental health professional and the gynecologist. In turn, the surgeons must commit to the extended care of this unique population, which, by definition, will protract well into the future.

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Female to Male Surgery for Trans Men

As a transgender male, your goal for female to male surgery (FTM) for gender-confirmation can involve top surgery, bottom surgery, or both. You may or may not want facial procedures. It’s up to you.

Female to Male Surgery at UVA

We’re here to offer consultations, second opinions, and information to help you choose and plan. Come to us with your questions and concerns. We’ll explain:

• Procedure options and details
• Recovery and healing
• What to expect of your results

We want you to feel confident about the direction and quality of your care.

Charley's Gender-Confirmation Surgery

From a young age, Charley Burton knew that his body did not match his gender identity – a struggle he kept inside for 50 years. With the help of family nurse practitioner Reagan Thompson, FNP, MSN, RN, and a whole team of caring providers, Charley found a safe place to become his true self. View Charley's story transcript.

FTM Top Surgery

To give you a flatter chest, we’ll have to remove breast tissue. We might also need to move and shrink your areolas.

If you have smaller breasts, we can sometimes use liposuction, which doesn’t involve many incisions.

Larger breasts may require the “double incision” technique. This method saves the pectoralis major muscle, the most defining characteristic of a male chest.

Whatever your breast size, we will use the techniques that optimize the results.

FTM Bottom Surgery

We can give you male genitalia in two different ways:

• Phalloplasty creates a penis and urethra (to stand while urinating). We use tissue from your forearm or thigh. We do this in 2 stages.
• Metoidioplasty takes your existing genital tissue and makes it longer, turning it into a defined phallus. This needs only one surgery.

You may or may not want to also have an operation to remove your internal reproductive organs. A hysterectomy takes out your uterus, fallopian tubes, and ovaries.

Facial Masculinization

Through a combination of procedures, we can sculpt your chin, jaw, and cheeks to appear more masculine. We can also reshape your nose and make your Adam’s apple look bigger. We can use synthetic implants for this work.

Questions? See our  transgender surgery FAQs .

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Female to Male Gender Reassignment Surgery (FTM GRS)

Female-to-male gender reassignment surgery (FTM GRS) is a complex and irreversible genital surgery for female transsexual who is diagnosed with gender identity disorder and has a strong desire to live as male. The procedure is to remove all female genital organs including the uterus, ovaries, and vagina with the construction of male genitalia composed of the penis and scrotum.  

The patient who is fit for this surgery must strictly follow the standard of care set by the World Professional Association of Transgender Healthcare (WPATH) or equivalent criteria; Express desire or live in another gender role (Female gender) long enough, under hormonal replacement therapy, evaluated and approved by a psychiatrist or other qualified professional gender therapist.  

Apart from genital surgery, the patient would seek other procedures to allow them to live as males smoothly such as breast amputation, facial surgery, body surgery, etc.  

Interested in having this procedure?

Useful Information

Ensure you consider all aspects of a procedure. You can speak to your surgeon about these areas of the surgery in more detail during a consultation.

The surgery is very complicated and only a handful of surgeons are able to perform this procedure. It is a multi-staged procedure, the first stage is the removal of the uterus, ovary, and vagina. The duration of the procedure is 2-3 hours. The second and later stages are penis and scrotum reconstruction which is at least 6 months later. There are several techniques for penile reconstruction depending on the type of tissue such as skin/fat of the forearm, skin/fat of the thigh, or adjacent tissue around the clitoris. This second stage of surgical time is between 3-5 hours. A penile prosthesis can be incorporated simultaneously or at a later stage. The scrotal prosthesis is also implanted later.  

The procedure is done under general anesthesia and might be combined with spinal anesthesia for faster recovery by reducing the usage of anesthetic gas.  

Inpatient/Outpatient

The patient will be hospitalized as an in-patient for between 5-7 days for each stage depending on the technique and surgeon. The patient will have a urinary catheter at all times in the hospital.  

Additional Information

What are the risks.

The most frequent complication of FTM GRS is bleeding, wound infection, skin flap or graft necrosis, urinary stenosis and fistula, unsightly scar, etc. The revision procedure is scar revision, hair transplant, or tattooing to camouflage unsightly scars.   

What is the recovery process?

During hospitalization, the patient must be restricted in bed continuously or intermittently for several days between 3-5 days. After release from the hospital, the patients return to their normal lives but not having to do physical exercise during the first 2 months after surgery. The patient will have a urinary catheter continuously for several weeks to avoid a urinary fistula. If the patient has a penile prosthesis, it would need at least 6 months before sexual intimacy.  

What are the results?

With good surgical technique, the result is very satisfying with an improved quality of life. The patient is able to live in a male role completely and happily either on their own or with their female or male partners.  

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Original research article, male-to-female gender-affirming surgery: 20-year review of technique and surgical results.

• 1 Serviço de Urologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
• 2 Serviço de Psiquiatria, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
• 3 Serviço de Psiquiatria, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil

Purpose: Gender dysphoria (GD) is an incompatibility between biological sex and personal gender identity; individuals harbor an unalterable conviction that they were born in the wrong body, which causes personal suffering. In this context, surgery is imperative to achieve a successful gender transition and plays a key role in alleviating the associated psychological discomfort. In the current study, a retrospective cohort, we report the 20-years outcomes of the gender-affirming surgery performed at a single Brazilian university center, examining demographic data, intra and postoperative complications. During this period, 214 patients underwent penile inversion vaginoplasty.

Results: Results demonstrate that the average age at the time of surgery was 32.2 years (range, 18–61 years); the average of operative time was 3.3 h (range 2–5 h); the average duration of hormone therapy before surgery was 12 years (range 1–39). The most commons minor postoperative complications were granulation tissue (20.5 percent) and introital stricture of the neovagina (15.4 percent) and the major complications included urethral meatus stenosis (20.5 percent) and hematoma/excessive bleeding (8.9 percent). A total of 36 patients (16.8 percent) underwent some form of reoperation. One hundred eighty-one (85 percent) patients in our series were able to have regular sexual intercourse, and no individual regretted having undergone GAS.

Conclusions: Findings confirm that it is a safety procedure, with a low incidence of serious complications. Otherwise, in our series, there were a high level of functionality of the neovagina, as well as subjective personal satisfaction.

Introduction

Transsexualism (ICD-10) or Gender Dysphoria (GD) (DSM-5) is characterized by intense and persistent cross-gender identification which influences several aspects of behavior ( 1 ). The terms describe a situation where an individual's gender identity differs from external sexual anatomy at birth ( 1 ). Gender identity-affirming care, for those who desire, can include hormone therapy and affirming surgeries, as well as other procedures such as hair removal or speech therapy ( 1 ).

Since 1998, the Gender Identity Program (PROTIG) of the Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul, Brazil has provided public assistance to transsexual people, is the first one in Brazil and one of the pioneers in South America. Our program offers psychosocial support, health care, and guidance to families, and refers individuals for gender-affirming surgery (GAS) when indicated. To be eligible for this surgery, transsexual individuals must have been adherent to multidisciplinary follow-up for at least 2 years, have a minimum age of 21 years (required for surgical procedures of this nature), have a positive psychiatric or psychological report, and have a diagnosis of GD.

Gender-affirming surgery (GAS) is increasingly recognized as a therapeutic intervention and a medical necessity, with growing societal acceptance ( 2 ). At our institution, we perform the classic penile inversion vaginoplasty (PIV), with an inverted penis skin flap used as the lining for the neovagina. Studies have demonstrated that GAS for the management of GD can promote improvements in mental health and social relationships for these patients ( 2 – 5 ). It is therefore imperative to understand and establish best practice techniques for this patient population ( 2 ). Although there are several studies reporting the safety and efficacy of gender-affirming surgery by penile inversion vaginoplasty, we present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

Patients and Methods

Subjects and study setup.

This is a retrospective cohort study of Brazilian transgender women who underwent penile inversion vaginoplasty between January of 2000 and March of 2020 at the Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. The study was approved by our institutional medical and research ethics committee.

At our institution, gender-affirming surgery is indicated for transgender women who are under assistance by our program for transsexual individuals. All transsexual women included in this study had at least 2 years of experience as a woman and met WPATH standards for GAS ( 1 ). Patients were submitted to biweekly group meetings and monthly individual therapy.

Between January of 2000 and March of 2020, a total of 214 patients underwent penile inversion vaginoplasty. The surgical procedures were performed by two separate staff members, mostly assisted by residents. A retrospective chart review was conducted recording patient demographics, intraoperative and postoperative complications, reoperations, and secondary surgical procedures. Informed consent was obtained from all individual participants included in the study.

Hormonal Therapy

The goal of feminizing hormone therapy is the development of female secondary sex characteristics, and suppression/minimization of male secondary sex characteristics.

Our general therapy approach is to combine an estrogen with an androgen blocker. The usual estrogen is the oral preparation of estradiol (17-beta estradiol), starting at a dose of 2 mg/day until the maximum dosage of 8 mg/day. The preferred androgen blocker is spironolactone at a dose of 200 mg twice a day.

Operative Technique

At our institution, we perform the classic penile inversion vaginoplasty, with an inverted penis skin flap used as the lining for the neovagina. For more details, we have previously published our technique with a step-by-step procedure video ( 6 ). All individuals underwent intestinal cleansing the evening before the surgery. A first-generation cephalosporin was used as preoperative prophylaxis. The procedure was performed with the patient in a dorsal lithotomy position. A Foley catheter was placed for bladder catheterization. A inverted-V incision was made 4 cm above the anus and a flap was created. A neovaginal cavity was created between the prostate and the rectum with blunt dissection, in the Denonvilliers space, until the peritoneal fold, usually measuring 12 cm in extension and 6 cm in width. The incision was then extended vertically to expose the testicles and the spermatic cords, which were removed at the level of the external inguinal rings. A circumferential subcoronal incision was made ( Figure 1 ), the penis was de-gloved and a skin flap was created, with the de-gloved penis being passed through the scrotal opening ( Figure 2 ). The dorsal part of the glans and its neurovascular bundle were bluntly dissected away from the penile shaft ( Figure 3 ) as well as the urethra, which included a portion of the bulbospongious muscle ( Figure 4 ). The corpora cavernosa was excised up to their attachments at the symphysis pubis and ligated. The neoclitoris was shaped and positioned in the midline at the level of the symphysis pubis and sutured using interrupted 5-0 absorbable suture. The corpus spongiosum was reduced and the urethra was shortened, spatulated, and placed 1 cm below the neoclitoris in the midline and sutured using interrupted 4-0 absorbable suture. The penile skin flap was inverted and pulled into the neovaginal cavity to become its walls ( Figure 5 ). The excess of skin was then removed, and the subcutaneous tissue and the skin were closed using continuous 3-0 non-absorbable suture ( Figure 6 ). A neo mons pubis was created using a 0 absorbable suture between the skin and the pubic bone. The skin flap was fixed to the pubic bone using a 0 absorbable suture. A gauze impregnated with Vaseline and antibiotic ointment was left inside the neovagina, and a customized compressive bandage was applied ( Figure 7 —shows the final appearance after the completion of the procedures).

Figure 1 . The initial circumferential subcoronal incision.

Figure 2 . The de-gloved penis being passed through the scrotal opening.

Figure 3 . The dorsal part of the glans and its neurovascular bundle dissected away from the penile shaft.

Figure 4 . The urethra dissected including a portion of the bulbospongious muscle. The grey arrow shows the penile shaft and the white arrow shows the dissected urethra.

Figure 5 . The inverted penile skin flap.

Figure 6 . The neoclitoris and the urethra sutured in the midline and the neovaginal cavity.

Figure 7 . The final appearance after the completion of the procedures.

Postoperative Care and Follow-Up

The patients were usually discharged within 2 days after surgery with the Foley catheter and vaginal gauze packing in place, which were removed after 7 days in an ambulatorial attendance.

Our vaginal dilation protocol starts seven days after surgery: a kit of 6 silicone dilators with progressive diameter (1.1–4 cm) and length (6.5–14.5 cm) is used; dilation is done progressively from the smallest dilator; each size should be kept in place for 5 min until the largest possible size, which is kept for 3 h during the day and during the night (sleep), if possible. The process is performed daily for the first 3 months and continued until the patient has regular sexual intercourse.

The follow-up visits were performed 7 days, 1, 2, 3, 6, and 12 months after surgery ( Figure 8 ), and included physical examination and a quality-of-life questionnaire.

Figure 8 . Appearance after 1 month of the procedure.

Statistical Analysis

The statistical analysis was conducted using Statistical Product and Service Solutions Version 18.0 (SPSS). Outcome measures were intra-operative and postoperative complications, re-operations. Descriptive statistics were used to evaluate the study outcomes. Mean values and standard deviations or median values and ranges are presented as continuous variables. Frequencies and percentages are reported for dichotomous and ordinal variables.

Patient Demographics

During the period of the study, 214 patients underwent penile inversion vaginoplasty, performed by two staff surgeons, mostly assisted by residents ( Table 1 ). The average age at the time of surgery was 32.2 years (range 18–61 years). There was no significant increase or decrease in the ages of patients who underwent SRS over the study period (Fisher's exact test: P = 0.065; chi-square test: X 2 = 5.15; GL = 6; P = 0.525). The average of operative time was 3.3 h (range 2–5 h). The average duration of hormone therapy before surgery was 12 years (range 1–39). The majority of patients were white (88.3 percent). The most prevalent patient comorbidities were history of tobacco use (15 percent), human immunodeficiency virus infection (13 percent) and hypertension (10.7 percent). Other comorbidities are listed in Table 1 .

Table 1 . Patient demographics.

Multidisciplinary follow-up was comprised of 93.45% of patients following up with a urologist and 59.06% of patients continuing psychiatric follow-up, median follow-up time of 16 and 9.3 months after surgery, respectively.

Postoperative Results

The complications were classified according to the Clavien-Dindo score ( Table 2 ). The most common minor postoperative complications (Grade I) were granulation tissue (20.5 percent), introital stricture of the neovagina (15.4 percent) and wound dehiscence (12.6 percent). The major complications (Grade III-IV) included urethral stenosis (20.5 percent), urethral fistula (1.9 percent), intraoperative rectal injury (1.9 percent), necrosis (primarily along the wound edges) (1.4 percent), and rectovaginal fistula (0.9 percent). A total of 17 patients required blood transfusion (7.9 percent).

Table 2 . Complications after penile inversion vaginoplasty.

A total of 36 patients (16.8 percent) underwent some form of reoperation.

One hundred eighty-one (85 percent) patients in our series were able to have regular sexual vaginal intercourse, and no individual regretted having undergone GAS.

Penile inversion vaginoplasty is the gold-standard in gender-affirming surgery. It has good functional outcomes, and studies have demonstrated adequate vaginal depths ( 3 ). It is recognized not only as a cosmetic procedure, but as a therapeutic intervention and a medical necessity ( 2 ). We present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

The mean age of transsexual women who underwent GAS in our study was 32.2 years (range 18–61 years), which is lower than the mean age of patients in studies found in the literature. Two studies indicated that the mean ages of patients at time of GAS were 36.7 years and 41 years, respectively ( 4 , 5 ). Another study reported a mean age at time of GAS of 36 years and found there was a significant decrease in age at the time of GAS from 41 years in 1994 to 35 years in 2015 ( 7 ). According to the authors, this decrease in age is associated with greater tolerance and societal approval regarding individuals with GD ( 7 ).

There was no grade IV or grade V complications. Excessive bleeding noticed postoperatively occurred in 19 patients (8.9 percent) and blood transfusion was required in 17 cases (7.9 percent); all patients who required blood transfusions were operated until July 2011, and the reason for this rate of blood transfusion was not identified.

The most common intraoperative complication was rectal injury, occurring in 4 patients (1.9 percent); in all patients the lesion was promptly identified and corrected in 2 layers absorbable sutures. In 2 of these patients, a rectovaginal fistula became evident, requiring fistulectomy and colonic transit deviation. This is consistent with current literature, in which rectal injury is reported in 0.4–4.5 percent of patients ( 4 , 5 , 8 – 13 ). Goddard et al. suggested carefully checking for enterotomy after prostate and bladder mobilization by digital rectal examination ( 4 ). Gaither et al. ( 14 ) commented that careful dissection that closely follows the urethra along its track from the central tendon of the perineum up through the lower pole of the prostate is critical and only blunt dissection is encouraged after Denonvilliers' fascia is reached. Alternatively, a robotic-assisted approach to penile inversion vaginoplasty may aid in minimizing these complications. The proposed advantages of a robotic-assisted vaginoplasty include safer dissection to minimize the risk of rectal injury and better proximal vaginal fixation. Dy et al. ( 15 ) has had no rectal injuries or fistulae to date in his series of 15 patients, with a mean follow-up of 12 months.

In our series, we observed 44 cases (20.5 percent) of urethral meatus strictures. We credit this complication to the technique used in the initial 5 years of our experience, in which the urethra was shortened and sutured in a circular fashion without spatulation. All cases were treated with meatal dilatation and 11 patients required surgical correction, being performed a Y-V plastic reconstruction of the urethral meatus. In the literature, meatal strictures are relatively rare in male-to-female (MtF) GAS due to the spatulation of the urethra and a simple anastomosis to the external genitalia. Recent systematic reviews show an incidence of five percent in this complication ( 16 , 17 ). Other studies report a wide incidence of meatal stenosis ranging from 1.1 to 39.8 percent ( 4 , 8 , 11 ).

Neovagina introital stricture was observed in 33 patients (15.4 percent) in our study and impedes the possibility of neovaginal penetration and/or adversely affects sexual life quality. In the literature, the reported incidence of introital stenosis range from 6.7 to 14.5 percent ( 4 , 5 , 8 , 9 , 11 – 13 ). According to Hadj-Moussa et al. ( 18 ) a regimen of postoperative prophylactic dilation is crucial to minimize the development of this outcome. At our institution, our protocol for vaginal dilation started seven days after surgery and was performed three to four times a day during the first 3 months and was continued until the individual had regular sexual intercourse. We treated stenosis initially with dilation. In case of no response, we propose a surgical revision with diamond-shaped introitoplasty with relaxing incisions. In recalcitrant cases, we proposed to the patient a secondary vaginoplasty using a full-thickness skin graft of the lower abdomen.

One hundred eighty-one (85 percent) patients were classified as having a “functional vagina,” characterized as the capacity to maintain satisfactory sexual vaginal intercourse, since the mean neovaginal depth was not measured. In a review article, the mean neovaginal depth ranged from 10 to 13.5 cm, with the shallowest neovagina depth at 2.5 cm and the deepest at 18 cm ( 17 ). According to Salim et al. ( 19 ), in terms of postoperative functional outcomes after penile inversion vaginoplasty, a mean percentage of 75 percent (range from 33 to 87 percent) patients were having vaginal intercourse. Hess et al. found that 91.4% of patients who responded to a questionnaire were very satisfied (34.4%), satisfied (37.6%), or mostly satisfied (19.4%) with their sexual function after penile inversion vaginoplasty ( 20 ).

Poor cosmetic appearance of the vulva is common. Amend et al. reported that the most common reason for reoperation was cosmetic correction in the form of mons pubis and mucosa reduction in 50% of patients ( 16 ). We had no patient regrets about performing GAS, although 36 patients (16.8 percent) were reoperated due to cosmetic issues. Gaither et al. propose in order to minimize scarring to use a one-stage surgical approach and the lateralization of surgical scars to the groin ( 14 ). Frequently, cosmetic issues outcomes are often patient driven and preoperative patient education is necessary ( 14 ).

Analyzing the quality of life, in 2016, our health care group (PROTIG) published a study assessing quality of life before and after gender-affirming surgery in 47 patients using the diagnostic tool 100-item WHO Quality of Life Assessment (WHOQOL-100) ( 21 ). The authors found that GAS promotes the improvement of psychological aspects and social relations. However, even 1 year after GAS, MtF persons continue to report problems in physical and difficulty in recovering their independence. In a systematic review and meta-analysis of QOL and psychosocial outcomes in transsexual people, researchers verified that sex reassignment with hormonal interventions more likely corrects gender dysphoria, psychological functioning and comorbidities, sexual function, and overall QOL compared with sex reassignment without hormonal interventions, although there is a low level of evidence for this ( 22 ). Recently, Castellano et al. assessed QOL in 60 Italian transsexuals (46 transwomen and 14 transmen) at least 2 years after SRS using the WHOQOL-100 (general QOL score and quality of sexual life and quality of body image scores) to focus on the effects of hormonal therapy. Overall satisfaction improved after SRS, and QOL was similar to the controls ( 23 ). Bartolucci et al. evaluated the perception of quality of sexual life using four questions evaluating the sexual facet in individuals with gender dysphoria before SRS and the possible factors associated with this perception. The study showed that approximately half the subjects with gender dysphoria perceived their sexual life as “poor/dissatisfied” or “very poor/very dissatisfied” before SRS ( 24 ).

Our study has some limitations. The total number of operated patients is restricted within the long follow-up period. This is due to a limitation in our health system, which allows only 1 sexual reassignment surgery to be performed per month at our institution. Neovagin depth measurement was not performed routinely in the follow-up of operated patients.

Conclusions

The definitive treatment for patients with gender dysphoria is gender-affirming surgery. Our series demonstrates that GAS is a feasible surgery with low rates of serious complications. We emphasize the high level of functionality of the vagina after the procedure, as well as subjective personal satisfaction. Complications, especially minor ones, are probably underestimated due to the nature of the study, and since this is a surgical population, the results may not be generalizable for all transgender MTF individuals.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by Hospital de Clínicas de Porto Alegre. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

GM: conception and design, data acquisition, data analysis, interpretation, drafting the manuscript, review of the literature, critical revision of the manuscript and factual content, and statistical analysis. ML and TR: conception and design, data interpretation, drafting the manuscript, critical revision of the manuscript and factual content, and statistical analysis. DS, KS, AF, AC, PT, AG, and RC: conception and design, data acquisition and data analysis, interpretation, drafting the manuscript, and review of the literature. All authors contributed to the article and approved the submitted version.

This study was supported by the Fundo de Incentivo à Pesquisa e Eventos (FIPE - Fundo de Incentivo à Pesquisa e Eventos) of Hospital de Clínicas de Porto Alegre.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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22. Murad MH, Elamin MB, Garcia MZ, Mullan RJ, Murad A, Erwin PJ, et al. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol . (2010) 72:214–31. doi: 10.1111/j.1365-2265.2009.03625.x

23. Castellano E, Crespi C, Dell'Aquila C, Rosato R, Catalano C, Mineccia V, et al. Quality of life and hormones after sex reassignment surgery. J Endocrinol Invest . (2015) 38:1373–81. doi: 10.1007/s40618-015-0398-0

24. Bartolucci C, Gómez-Gil E, Salamero M, Esteva I, Guillamón A, Zubiaurre L, et al. Sexual quality of life in gender-dysphoric adults before genital sex reassignment surgery. J Sex Med . (2015) 12:180–8. doi: 10.1111/jsm.12758

Keywords: transsexualism, gender dysphoria, gender-affirming genital surgery, penile inversion vaginoplasty, surgical outcome

Citation: Moisés da Silva GV, Lobato MIR, Silva DC, Schwarz K, Fontanari AMV, Costa AB, Tavares PM, Gorgen ARH, Cabral RD and Rosito TE (2021) Male-to-Female Gender-Affirming Surgery: 20-Year Review of Technique and Surgical Results. Front. Surg. 8:639430. doi: 10.3389/fsurg.2021.639430

Received: 17 December 2020; Accepted: 22 March 2021; Published: 05 May 2021.

Reviewed by:

Copyright © 2021 Moisés da Silva, Lobato, Silva, Schwarz, Fontanari, Costa, Tavares, Gorgen, Cabral and Rosito. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Gabriel Veber Moisés da Silva, veber.gabriel@gmail.com

This article is part of the Research Topic

Gender Dysphoria: Diagnostic Issues, Clinical Aspects and Health Promotion

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FTM Gender Confirmation Solutions

The specifics, the takeaway.

Before and Afters

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A wide variety of plastic surgery procedures are available to assist transgender individuals in their gender confirmation experience.

Written By: Erin Storm, PA-C

Published: March 19, 2021

Last updated: October 07, 2021

• Who is a candidate for FTM procedures?
• What can you expect from a procedure?
• When should you consider FTM Surgery?
• What are some age considerations for FTM Surgery?

Facial Masculinization Procedures

Transmasculine top procedures, transmasculine bottom procedures.

• Body Contouring Procedures

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Related Procedures

Gender confirmation surgery or gender reassignment surgery can be a major component of a transgender individual’s transition. There are numerous surgical procedures from head to toe for female to male (FTM) transgender patients . Plastic surgery procedures are usually used in unison with medical and hormone therapies being administered under the guidance of a healthcare provider. You can also consult our male to female (MTF) gender confirmation guide .

All individuals planning to undergo a gender confirmation or gender reassignment transition are evaluated for physical, emotional, and mental health. These evaluations are used to provide whole patient considerations and maintain standards of care for transgender health and gender dysphoria. Multiple international and national organizations exist to advocate, educate, and cultivate a transgender community. The World Professional Association for Transgender Health (WPATH), American society offshoot USPATH , and GLAAD are just a few of these institutions.

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Who is a candidate for female to male gender confirmation surgeries?

What can you expect from female to male gender confirmation surgeries.

FTM gender confirmation surgeries vary greatly depending on an individual transgender candidate’s needs. There are both surgical and non-surgical treatment options for gender reassignment.

• Facial Masculinization : These procedures address the hair, face, and neck. There are surgical modalities to alter bony and soft tissue structures and also less invasive non-surgical options like fillers, thread lifts, and Botox.
• Transmasculine Top Surgery : Typically a surgical breast removal (mastectomy) is used. The nipples and areola are also usually altered to create a more male appearing chest.
• Transmasculine Bottom Surgery : These are typically surgical procedures to alter the buttocks, hips, legs, and genitals.
• Body Contouring : Liposuction is a minor surgical procedure, although other body contouring procedures may be less invasive and involve phototherapy or freezing techniques.

Generally, surgical procedures are more involved, but also permanent, and will necessitate weeks to months of recovery. Non-surgical options usually provide less permanent results, but are also less invasive, and possibly changeable. Some hair procedures may take many months to years to achieve full, lasting results. Medical and hormone therapies may possibly affect surgical procedures. There use should be discussed with your providers.

When should you consider female to male gender confirmation surgeries?

The decision to pursue any gender confirmation surgery is unique to each individual transgender patient. Considerations for physical and mental health are important components in deciding the appropriate time to pursue procedures. Additionally, candidates concurrently utilizing medical and hormone therapies will need to discuss the timing of surgical procedures with their plastic surgeon and medical provider.

What is the youngest age someone can have female to male gender confirmation surgeries?

Guidelines for pediatric candidates (those under age 18) seeking to pursue gender affirming surgeries state transgender individuals should not undergo genital reconstruction procedures such as phalloplasty (penile construction), scrotoplasty (scrotum construction), vaginoplasty (labia, clitoris, and vaginal construction), oophorectomy (ovary removal), or hysterectomy (uterus removal) until they reach age 18.

Certain top FTM procedures may be considered at age 16. A consultation with a certified medical provider is necessary to determine the best timing of all gender affirming procedures and therapies. Additionally, parental consent and full physical and mental health evaluations are required.

A combination of surgical and non-surgical procedures that address the forehead, hairline, nose, lips, cheeks, chin, neck, and more may be employed for facial masculinization.

Forehead Contouring & Hairline Advancement

• Brow Lift +
• Surgical Hair Restoration +

Rhinoplasty

• Surgical Rhinoplasty +
• Non-Surgical Rhinoplasty +

Cheek Augmentation

• Surgical Cheek Augmentation +

Lip Augmentation

• Surgical Lip Augmentation +
• Non-Surgical Lip Augmentation +

Chin Surgery

• Surgical Chin Augmentation +

Neck Procedures

• Adam's Apple Enhancement +

Breast removal and chest augmentation are the goals of transmasculine top procedures.

• Mastectomy + Nipple & Areola Surgery +
• Pectoral Implants +

Transmasuline bottom procedures can be used to remove female sex organs and create a penis and scrotum.

• Male Genital Construction +

Body Contouring

There are both surgical and non-surgical treatment options to shape and contour the body.

• Non-Surgical Body Contouring +
• Liposuction +
• Calf Augmentation via Implant +

For transgender individuals considering integratin gender confirmation surgeries into their transition, there exists a wide array of procedures to further refine, define, and create their desired aesthetic. A plastic surgeon will assist with both sex reassignment surgeries and cosmetic transgender surgeries in unison with medical and hormone therapies administered by a healthcare provider. Candidates should also consider discussing with their insurance companies possible coverages for some of these procedures in the treatment of gender dysphoria.

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• American Society of Plastic Surgeons Gender Confirmation Surgeries plasticsurgery.org
• Karel E Y Claes Chest Surgery for Transgender and Gender Nonconforming Individuals PubMed.gov ; 2018-07-02
• Hoyos, A, and M Perez Arm Dynamic Definition by Liposculpture and Fat Grafting Oxford Academic ; 2012-11-01
• GB Forbes Body Fat Content Influences the Body Composition Response to Nutrition and Exercise PubMed.gov ; 2000-05-01
• Paul Cohen, Bruce M Spiegelman Cell Biology of Fat Storage PubMed.gov ; 2016-08-15

FTM Gender Confirmation: Facial Masculinization

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FTM Gender Confirmation: Transmasculine Top & Bottom Surgeries

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• Feminizing surgery

Feminizing surgery, also called gender-affirming surgery or gender-confirmation surgery, involves procedures that help better align the body with a person's gender identity. Feminizing surgery includes several options, such as top surgery to increase the size of the breasts. That procedure also is called breast augmentation. Bottom surgery can involve removal of the testicles, or removal of the testicles and penis and the creation of a vagina, labia and clitoris. Facial procedures or body-contouring procedures can be used as well.

Not everybody chooses to have feminizing surgery. These surgeries can be expensive, carry risks and complications, and involve follow-up medical care and procedures. Certain surgeries change fertility and sexual sensations. They also may change how you feel about your body.

Your health care team can talk with you about your options and help you weigh the risks and benefits.

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Why it's done

Many people seek feminizing surgery as a step in the process of treating discomfort or distress because their gender identity differs from their sex assigned at birth. The medical term for this is gender dysphoria.

For some people, having feminizing surgery feels like a natural step. It's important to their sense of self. Others choose not to have surgery. All people relate to their bodies differently and should make individual choices that best suit their needs.

Feminizing surgery may include:

• Removal of the testicles alone. This is called orchiectomy.
• Removal of the penis, called penectomy.
• Removal of the testicles.
• Creation of a vagina, called vaginoplasty.
• Creation of a clitoris, called clitoroplasty.
• Creation of labia, called labioplasty.
• Breast surgery. Surgery to increase breast size is called top surgery or breast augmentation. It can be done through implants, the placement of tissue expanders under breast tissue, or the transplantation of fat from other parts of the body into the breast.
• Plastic surgery on the face. This is called facial feminization surgery. It involves plastic surgery techniques in which the jaw, chin, cheeks, forehead, nose, and areas surrounding the eyes, ears or lips are changed to create a more feminine appearance.
• Tummy tuck, called abdominoplasty.
• Buttock lift, called gluteal augmentation.
• Liposuction, a surgical procedure that uses a suction technique to remove fat from specific areas of the body.
• Voice feminizing therapy and surgery. These are techniques used to raise voice pitch.
• Tracheal shave. This surgery reduces the thyroid cartilage, also called the Adam's apple.
• Scalp hair transplant. This procedure removes hair follicles from the back and side of the head and transplants them to balding areas.
• Hair removal. A laser can be used to remove unwanted hair. Another option is electrolysis, a procedure that involves inserting a tiny needle into each hair follicle. The needle emits a pulse of electric current that damages and eventually destroys the follicle.

Your health care provider might advise against these surgeries if you have:

• Significant medical conditions that haven't been addressed.
• Behavioral health conditions that haven't been addressed.
• Any condition that limits your ability to give your informed consent.

Like any other type of major surgery, many types of feminizing surgery pose a risk of bleeding, infection and a reaction to anesthesia. Other complications might include:

• Delayed wound healing
• Fluid buildup beneath the skin, called seroma
• Bruising, also called hematoma
• Changes in skin sensation such as pain that doesn't go away, tingling, reduced sensation or numbness
• Damaged or dead body tissue — a condition known as tissue necrosis — such as in the vagina or labia
• A blood clot in a deep vein, called deep vein thrombosis, or a blood clot in the lung, called pulmonary embolism
• Development of an irregular connection between two body parts, called a fistula, such as between the bladder or bowel into the vagina
• Urinary problems, such as incontinence
• Pelvic floor problems
• Permanent scarring
• Loss of sexual pleasure or function
• Worsening of a behavioral health problem

Certain types of feminizing surgery may limit or end fertility. If you want to have biological children and you're having surgery that involves your reproductive organs, talk to your health care provider before surgery. You may be able to freeze sperm with a technique called sperm cryopreservation.

How you prepare

Before surgery, you meet with your surgeon. Work with a surgeon who is board certified and experienced in the procedures you want. Your surgeon talks with you about your options and the potential results. The surgeon also may provide information on details such as the type of anesthesia that will be used during surgery and the kind of follow-up care that you may need.

Follow your health care team's directions on preparing for your procedures. This may include guidelines on eating and drinking. You may need to make changes in the medicine you take and stop using nicotine, including vaping, smoking and chewing tobacco.

Because feminizing surgery might cause physical changes that cannot be reversed, you must give informed consent after thoroughly discussing:

• Risks and benefits
• Alternatives to surgery
• Expectations and goals
• Social and legal implications
• Potential complications
• Impact on sexual function and fertility

Evaluation for surgery

Before surgery, a health care provider evaluates your health to address any medical conditions that might prevent you from having surgery or that could affect the procedure. This evaluation may be done by a provider with expertise in transgender medicine. The evaluation might include:

• A review of your personal and family medical history
• A physical exam
• A review of your vaccinations
• Screening tests for some conditions and diseases
• Identification and management, if needed, of tobacco use, drug use, alcohol use disorder, HIV or other sexually transmitted infections
• Discussion about birth control, fertility and sexual function

You also may have a behavioral health evaluation by a health care provider with expertise in transgender health. That evaluation might assess:

• Gender identity
• Gender dysphoria
• Mental health concerns
• Sexual health concerns
• The impact of gender identity at work, at school, at home and in social settings
• The role of social transitioning and hormone therapy before surgery
• Risky behaviors, such as substance use or use of unapproved hormone therapy or supplements
• Support from family, friends and caregivers
• Your goals and expectations of treatment
• Care planning and follow-up after surgery

Other considerations

Health insurance coverage for feminizing surgery varies widely. Before you have surgery, check with your insurance provider to see what will be covered.

Before surgery, you might consider talking to others who have had feminizing surgery. If you don't know someone, ask your health care provider about support groups in your area or online resources you can trust. People who have gone through the process may be able to help you set your expectations and offer a point of comparison for your own goals of the surgery.

What you can expect

Facial feminization surgery.

Facial feminization surgery may involve a range of procedures to change facial features, including:

• Moving the hairline to create a smaller forehead
• Enlarging the lips and cheekbones with implants
• Reshaping the jaw and chin
• Undergoing skin-tightening surgery after bone reduction

These surgeries are typically done on an outpatient basis, requiring no hospital stay. Recovery time for most of them is several weeks. Recovering from jaw procedures takes longer.

Tracheal shave

A tracheal shave minimizes the thyroid cartilage, also called the Adam's apple. During this procedure, a small cut is made under the chin, in the shadow of the neck or in a skin fold to conceal the scar. The surgeon then reduces and reshapes the cartilage. This is typically an outpatient procedure, requiring no hospital stay.

Top surgery

• Breast augmentation incisions

As part of top surgery, the surgeon makes cuts around the areola, near the armpit or in the crease under the breast.

• Placement of breast implants or tissue expanders

During top surgery, the surgeon places the implants under the breast tissue. If feminizing hormones haven't made the breasts large enough, an initial surgery might be needed to have devices called tissue expanders placed in front of the chest muscles.

Hormone therapy with estrogen stimulates breast growth, but many people aren't satisfied with that growth alone. Top surgery is a surgical procedure to increase breast size that may involve implants, fat grafting or both.

During this surgery, a surgeon makes cuts around the areola, near the armpit or in the crease under the breast. Next, silicone or saline implants are placed under the breast tissue. Another option is to transplant fat, muscles or tissue from other parts of the body into the breasts.

If feminizing hormones haven't made the breasts large enough for top surgery, an initial surgery may be needed to place devices called tissue expanders in front of the chest muscles. After that surgery, visits to a health care provider are needed every few weeks to have a small amount of saline injected into the tissue expanders. This slowly stretches the chest skin and other tissues to make room for the implants. When the skin has been stretched enough, another surgery is done to remove the expanders and place the implants.

Genital surgery

• Anatomy before and after penile inversion

During penile inversion, the surgeon makes a cut in the area between the rectum and the urethra and prostate. This forms a tunnel that becomes the new vagina. The surgeon lines the inside of the tunnel with skin from the scrotum, the penis or both. If there's not enough penile or scrotal skin, the surgeon might take skin from another area of the body and use it for the new vagina as well.

• Anatomy before and after bowel flap procedure

A bowel flap procedure might be done if there's not enough tissue or skin in the penis or scrotum. The surgeon moves a segment of the colon or small bowel to form a new vagina. That segment is called a bowel flap or conduit. The surgeon reconnects the remaining parts of the colon.

Orchiectomy

Orchiectomy is a surgery to remove the testicles. Because testicles produce sperm and the hormone testosterone, an orchiectomy might eliminate the need to use testosterone blockers. It also may lower the amount of estrogen needed to achieve and maintain the appearance you want.

This type of surgery is typically done on an outpatient basis. A local anesthetic may be used, so only the testicular area is numbed. Or the surgery may be done using general anesthesia. This means you are in a sleep-like state during the procedure.

To remove the testicles, a surgeon makes a cut in the scrotum and removes the testicles through the opening. Orchiectomy is typically done as part of the surgery for vaginoplasty. But some people prefer to have it done alone without other genital surgery.

Vaginoplasty

Vaginoplasty is the surgical creation of a vagina. During vaginoplasty, skin from the shaft of the penis and the scrotum is used to create a vaginal canal. This surgical approach is called penile inversion. In some techniques, the skin also is used to create the labia. That procedure is called labiaplasty. To surgically create a clitoris, the tip of the penis and the nerves that supply it are used. This procedure is called a clitoroplasty. In some cases, skin can be taken from another area of the body or tissue from the colon may be used to create the vagina. This approach is called a bowel flap procedure. During vaginoplasty, the testicles are removed if that has not been done previously.

Some surgeons use a technique that requires laser hair removal in the area of the penis and scrotum to provide hair-free tissue for the procedure. That process can take several months. Other techniques don't require hair removal prior to surgery because the hair follicles are destroyed during the procedure.

After vaginoplasty, a tube called a catheter is placed in the urethra to collect urine for several days. You need to be closely watched for about a week after surgery. Recovery can take up to two months. Your health care provider gives you instructions about when you may begin sexual activity with your new vagina.

After surgery, you're given a set of vaginal dilators of increasing sizes. You insert the dilators in your vagina to maintain, lengthen and stretch it. Follow your health care provider's directions on how often to use the dilators. To keep the vagina open, dilation needs to continue long term.

Because the prostate gland isn't removed during surgery, you need to follow age-appropriate recommendations for prostate cancer screening. Following surgery, it is possible to develop urinary symptoms from enlargement of the prostate.

Dilation after gender-affirming surgery

This material is for your education and information only. This content does not replace medical advice, diagnosis and treatment. If you have questions about a medical condition, always talk with your health care provider.

Narrator: Vaginal dilation is important to your recovery and ongoing care. You have to dilate to maintain the size and shape of your vaginal canal and to keep it open.

Jessi: I think for many trans women, including myself, but especially myself, I looked forward to one day having surgery for a long time. So that meant looking up on the internet what the routines would be, what the surgery entailed. So I knew going into it that dilation was going to be a very big part of my routine post-op, but just going forward, permanently.

Narrator: Vaginal dilation is part of your self-care. You will need to do vaginal dilation for the rest of your life.

Alissa (nurse): If you do not do dilation, your vagina may shrink or close. If that happens, these changes might not be able to be reversed.

Narrator: For the first year after surgery, you will dilate many times a day. After the first year, you may only need to dilate once a week. Most people dilate for the rest of their life.

Jessi: The dilation became easier mostly because I healed the scars, the stitches held up a little bit better, and I knew how to do it better. Each transgender woman's vagina is going to be a little bit different based on anatomy, and I grew to learn mine. I understand, you know, what position I needed to put the dilator in, how much force I needed to use, and once I learned how far I needed to put it in and I didn't force it and I didn't worry so much on oh, did I put it in too far, am I not putting it in far enough, and I have all these worries and then I stress out and then my body tenses up. Once I stopped having those thoughts, I relaxed more and it was a lot easier.

Narrator: You will have dilators of different sizes. Your health care provider will determine which sizes are best for you. Dilation will most likely be painful at first. It's important to dilate even if you have pain.

Alissa (nurse): Learning how to relax the muscles and breathe as you dilate will help. If you wish, you can take the pain medication recommended by your health care team before you dilate.

Narrator: Dilation requires time and privacy. Plan ahead so you have a private area at home or at work. Be sure to have your dilators, a mirror, water-based lubricant and towels available. Wash your hands and the dilators with warm soapy water, rinse well and dry on a clean towel. Use a water-based lubricant to moisten the rounded end of the dilators. Water-based lubricants are available over-the-counter. Do not use oil-based lubricants, such as petroleum jelly or baby oil. These can irritate the vagina. Find a comfortable position in bed or elsewhere. Use pillows to support your back and thighs as you lean back to a 45-degree angle. Start your dilation session with the smallest dilator. Hold a mirror in one hand. Use the other hand to find the opening of your vagina. Separate the skin. Relax through your hips, abdomen and pelvic floor. Take slow, deep breaths. Position the rounded end of the dilator with the lubricant at the opening to your vaginal canal. The rounded end should point toward your back. Insert the dilator. Go slowly and gently. Think of its path as a gentle curving swoop. The dilator doesn't go straight in. It follows the natural curve of the vaginal canal. Keep gentle down and inward pressure on the dilator as you insert it. Stop when the dilator's rounded end reaches the end of your vaginal canal. The dilators have dots or markers that measure depth. Hold the dilator in place in your vaginal canal. Use gentle but constant inward pressure for the correct amount of time at the right depth for you. If you're feeling pain, breathe and relax the muscles. When time is up, slowly remove the dilator, then repeat with the other dilators you need to use. Wash the dilators and your hands. If you have increased discharge following dilation, you may want to wear a pad to protect your clothing.

Jessi: I mean, it's such a strange, unfamiliar feeling to dilate and to have a dilator, you know to insert a dilator into your own vagina. Because it's not a pleasurable experience, and it's quite painful at first when you start to dilate. It feels much like a foreign body entering and it doesn't feel familiar and your body kind of wants to get it out of there. It's really tough at the beginning, but if you can get through the first month, couple months, it's going to be a lot easier and it's not going to be so much of an emotional and uncomfortable experience.

Narrator: You need to stay on schedule even when traveling. Bring your dilators with you. If your schedule at work creates challenges, ask your health care team if some of your dilation sessions can be done overnight.

Alissa (nurse): You can't skip days now and do more dilation later. You must do dilation on schedule to keep vaginal depth and width. It is important to dilate even if you have pain. Dilation should cause less pain over time.

Jessi: I hear that from a lot of other women that it's an overwhelming experience. There's lots of emotions that are coming through all at once. But at the end of the day for me, it was a very happy experience. I was glad to have the opportunity because that meant that while I have a vagina now, at the end of the day I had a vagina. Yes, it hurts, and it's not pleasant to dilate, but I have the vagina and it's worth it. It's a long process and it's not going to be easy. But you can do it.

Narrator: If you feel dilation may not be working or you have any questions about dilation, please talk with a member of your health care team.

Research has found that that gender-affirming surgery can have a positive impact on well-being and sexual function. It's important to follow your health care provider's advice for long-term care and follow-up after surgery. Continued care after surgery is associated with good outcomes for long-term health.

Before you have surgery, talk to members of your health care team about what to expect after surgery and the ongoing care you may need.

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Feminizing surgery care at Mayo Clinic

• Tangpricha V, et al. Transgender women: Evaluation and management. https://www.uptodate.com/ contents/search. Accessed Aug. 16, 2022.
• Erickson-Schroth L, ed. Surgical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Aug. 17, 2022.
• Coleman E, et al. Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health. 2022; doi:10.1080/26895269.2022.2100644.
• AskMayoExpert. Gender-affirming procedures (adult). Mayo Clinic; 2022.
• Nahabedian, M. Implant-based breast reconstruction and augmentation. https://www.uptodate.com/contents/search. Accessed Aug. 17, 2022.
• Erickson-Schroth L, ed. Medical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Aug. 17, 2022.
• Ferrando C, et al. Gender-affirming surgery: Male to female. https://www.uptodate.com/contents/search. Accessed Aug. 17, 2022.
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