Gender Confirmation Surgeries Transfeminine / Transmasculine
What surgical options are available to transgender and gender non-conforming patients? Gender confirmation surgeries are performed by a multispecialty team that typically includes board-certified plastic surgeons. The goal is to give transgender individuals the physical appearance and functional abilities of the gender they know themselves to be. Listed below are many of the available procedures for transwomen (MTF) and transmen (FTM) to aid in their journey.
The goal of facial feminization surgery is to transform the masculine features of the face to a more feminine appearance.
The goal of transfeminine top surgery is to enhance the size and shape of the breasts to create a more feminine appearance to the chest.
The goal of transfeminine bottom surgery is to transform the male genitalia and reconstruct it into that of a female. Transfeminine bottom surgery is typically performed as a single stage procedure.
The goal of facial masculinization surgery is to transform the feminine features of the face to a more masculine appearance.
The goal of transmasculine top surgery is to remove the breast tissue (mastectomy) from both breasts and create a masculine appearance to the chest.
The goal of transmasculine bottom surgery is to transform the female genitalia and reconstruct it into that of a male. Transmasculine bottom surgery is typically performed as a multiple stage procedure.
What are female-to-male gender confirmation surgeries?
For patients with severe gender dysphoria, or gender incongruence, surgery has been a mainstay of treatment for decades. Recently, Medicare lifted a 33 year ban on gender confirmation surgeries, as the benefits are clear in a well-screened patient population and the surgeries are no longer considered experimental. Facial feminizing surgery, breast augmentation, and vaginoplasty may be pursued by male-to-female patients. Likewise, for female-to-male patients, chest masculinizing surgery, hysterectomy and genital reconstruction are often pursued.
Chest masculinizing surgery is a procedure whereby breast tissue and excess skin are removed from a female-to-male patient, and the chest and nipple areolar complex are reconstructed to appear masculinized. Depending on the size of the patient’s chest, either the keyhole (subcutaneous mastectomy) or double incision (simple mastectomy) techniques are utilized. In most cases, the nipple areolar complex is also resized and reshaped. Either procedure is typically outpatient, and most patients return to work within two weeks. The surgery is well-tolerated by most and, in experienced hands, complications such as infection, wound healing difficulties and nipple areolar loss are rare.
There are several options for genital reconstruction for a transgendered man. A metoidioplasty is a local tissue rearrangement that is outpatient and can be safely performed at the same time as a hysterectomy in some centers. This typically creates a phallus that is one to three inches long, depending on the amount of growth that has been achieved on testosterone. The meta can also contain a urethra, allowing a patient to stand to urinate. Scrotoplasty and vaginectomy may be performed in the same surgical setting. Testicular implants are often placed in the scrotum at a separate surgery. Most patients return to work within four to six weeks. The best candidates are those that are close to ideal body weight and have had genital enlargement on testosterone. With any urethral lengthening procedure, complications such as urethral stricture or fistula are possible.
Phalloplasty is a general term used to indicate that a phallus is being constructed by any one of a variety of surgical techniques. The current mainstay of treatment utilizes a sensate pedicled flap or a microsurgical free flap technique. Local flaps such as the groin flap or abdominal tube flap typically yield a phallus with no sensation and are usually devoid of a urethra. More modern techniques utilize a microsurgical dissection allowing for a nerve, artery, and vein to be reattached after distant tissue is transferred to the site where the phallus should reside. Common donor sites include the forearm, back, or thigh. Most patients return to work in eight to ten weeks, but some require more time off if complications should arise. Growth of genital tissue on testosterone is not as important in phalloplasty because the tissue utilized to build the phallus is brought in from some other donor site on the body. Good candidates include those with a body mass index of less than 35 and who are healthy enough for the lengthy eight-hour procedure. The most devastating complication is total flap loss, or loss of the tissue being used to create the phallus. This typically occurs because of a blood clot forming in the vasculature. In experienced centers, this risk is usually less than 3%.
Plastic surgery an important step in gender dysphoria treatment of transgender individuals
Individuals with gender dysphoria often describe being born in the wrong body, and plastic surgery is an important step in aligning their bodies with whom they know themselves to be.
To guide transition, the World Professional Association for Transgender Health (WPATH) developed the The Standards of Care to help provide “the highest standards” of care for individuals with gender dysphoria. Accordingly, the overarching treatment goal is “…lasting personal comfort with the gendered self, in order to maximize overall health, psychological well-being and self-fulfillment.”
Several surgical procedures are available for transgender females (individuals transitioning from male to female.) Successful genital reconstruction involves the creation of a natural-appearing vagina and mons pubis that is both sensate and functional. This includes a feminine-appearing labia majora and minora, removal of the stigmatizing scrotum, a sensate neoclitoris, and adequate vaginal depth and introital width for intercourse. Additional desirable qualities include a moist appearance to the labia minora, clitoral hooding and lubrication for intercourse.
Aside from female genital reconstruction, other procedures designed to feminize one’s appearance include breast augmentation, thyroid chondrolaryngoplasty (“tracheal shave”) and facial feminization.
Genital reconstruction can also be performed in transgender males (individuals transitioning from female to male). Phalloplasty represents the most complete genito-perineal transformation and requires use of tissue from a distant donor site. Phalloplasty can be performed with urethral reconstruction to allow for urination while standing, and implantable prostheses (testicular and penile) can be placed in subsequent procedures.
An alternative to phalloplasty, metoidioplasty involves lengthening of the virilized clitoris to create a micropenis. Metoidioplasty can also be performed with urethral lengthening so as to allow an individual to urinate while standing.
Additional procedures, such as “chest surgery,” include bilateral subcutaneous mastectomies, chest contouring and repositioning and re-sizing of the nipple-areola complex. Several different techniques are employed; the choice of technique depends upon the volume of breast parenchyma, degree of breast ptosis and position of the nipple-areola complex, and degree of skin elasticity.