Masculinizing surgeries

Masculinizing surgeries

Overview

Masculinizing surgery includes many options, such as "top" surgery to remove your breasts and create a more male-contoured chest and "bottom" surgery to increase the length of the clitoris (metoidioplasty), create a penis (phalloplasty) or create a scrotum (scrotoplasty).

Why it's done

People who seek masculinizing surgery experience distress due to a difference between experienced or expressed gender and sex assigned at birth (gender dysphoria).

For some trans men (female to male), masculinizing surgery is a natural step — and important to their sense of self. However, many don't choose to have surgery. Transgender people relate to their bodies differently and need to make individual choices that best suit their needs.

Masculinizing surgeries are typically deferred until adulthood. Options include:

• Surgical removal of your breast tissue (mastectomy)
• Surgical placement of implants behind your pectoral muscles to create the appearance of a defined male chest (pectoral implants)
• Various aesthetic procedures, such as a surgical procedure that uses a suction technique to remove fat from specific areas of the body (liposuction) or fat grafting
• Genital surgery to remove your uterus (hysterectomy), or uterus and cervix (total hysterectomy), or fallopian tubes and ovaries (salpingo-oophorectomy)
• Surgery to remove all or part of your vagina (vaginectomy), create a scrotum (scrotoplasty), place testicular prostheses, increase the length of the clitoris (metoidioplasty) or create a penis (phalloplasty)

How you prepare for surgery?

Masculinizing surgeries are typically deferred until adulthood.

Hormone therapy isn't required before top surgery for transgender men. In some, waiting for the chest muscle growth that occurs with testosterone therapy will provide the best surgical result. If you've been taking testosterone therapy, you'll have blood tests to ensure the testosterone level is in your target range.

Before surgery, you'll meet with your surgeon. Consult a surgeon who is board certified and experienced in this procedure. Your surgeon will describe your options and potential results. The surgeon will provide information on the anesthesia, the location of the operation and the kind of follow-up procedures that might be necessary. Follow your doctor's specific instructions on preparing for your procedures, including guidelines on eating and drinking, adjusting current medications, and quitting smoking.

In addition, before you can have top surgery, you'll be required to meet certain criteria. To start, your doctor will evaluate your health to rule out or address any medical conditions that might affect or contraindicate treatment. The evaluation might include:

A review of your personal and family medical history

A physical exam, including an assessment of your internal reproductive organs

Lab tests measuring your lipids, blood sugar, blood count, liver enzymes and electrolytes

• A review of your immunizations
• Age- and sex-appropriate screenings
• Identification and management of tobacco use, drug abuse, alcohol abuse, HIV and other sexually transmitted infections
• Discussion about contraception and future fertility

Although giving your informed consent after a discussion about the risks and benefits of the procedure is an acceptable standard of care, most surgeons and insurance companies will require a mental health evaluation by a provider with expertise in transgender health. The evaluation might assess:

• Your gender identity and dysphoria
• The impact of your gender identity at work, school, home and social environments, including issues related to discrimination, relationship abuse and minority stress
• Mood or other mental health concerns
• Sexual health concerns
• Risk-taking behaviors, including substance use and use of nonmedical-grade silicone injections or unapproved hormone therapy or supplements
• Protective factors such as social support from family, friends and peers
• Your goals, risks and expectations of treatment and your future care plans

What you can expect

Chest surgery

Masculinizing chest surgery involves the removal of your breast tissue (double mastectomy). If your breast size is small, you might be able to have surgery that spares your skin, nipple and areola (nipple-sparing subcutaneous mastectomy). This procedure minimizes scarring, has a faster healing time and usually preserves erotic sensation in the nipples. If you have larger breasts, you might need to have your nipples and areolas taken off, resized and grafted back into position. This causes more scarring and loss of erotic sensation to the nipple.

If you are a carrier of genetic mutations that increase your risk of breast cancer, you might also choose to have your nipples and areolas completely removed and subsequent surgery or tattooing to recreate their appearance.

After surgery, you might need to stay in the hospital overnight. You'll likely have one or two small plastic tubes placed where your breasts were removed to drain any fluids that accumulate after surgery. You might not be able to bear weight on your upper body for six weeks.

Some breast tissue will likely remain regardless of the surgical technique. As a result, your doctor will talk to you about the need for continuing routine breast cancer screening.

Genital surgery

Metoidioplasty

What is Metoidioplasty surgery?

Metoidioplasty, also known as meta, is a term used to describe surgical procedures that work with your existing genital tissue to form what is called a neophallus, or new penis, Most doctors recommend being on testosterone therapy for one to two years before having metoidioplasty

What are the different types of metoidioplasty?

There are four basic types of metoidioplasty procedures:

Simple release

• Also known as simple meta, this procedure consists only of the clitoral release that is, a procedure to free the clitoris from surrounding tissue and doesn’t alter the urethra or vagina. Simple release increases the length and exposure of your penis.

Full metoidioplasty

• Surgeons who perform full metoidioplasty release the clitoris and then use a tissue graft from the inside of your cheek to link the urethra with the neophallus. If desired, they may also perform vaginectomy (removal of the vagina) and insert scrotal implants.

Ring metoidioplasty

• This procedure is very similar to full metoidioplasty. However, instead of taking a skin graft from the inside of the mouth, the surgeon uses a graft from the inside of the vaginal wall combined with the labia majora in order to connect the urethra and the neophallus.
• The advantage to this procedure is that you’ll only have to heal at one site as opposed to two. You also won’t experience complications that may arise from surgery in the mouth such as pain while eating and decreased production of saliva.

Centurion metoidioplasty

• The Centurion procedure releases the round ligaments that run up the labia from the labia majora, and then uses them to surround the new penis, creating extra girth. Unlike other procedures, Centurion doesn’t require that a skin graft be taken from the mouth or from the vaginal wall, meaning there is less pain, less scarring, and fewer complications.

Phalloplasty

Phalloplasty, the surgical creation of a penis, involves multiple procedures. During phalloplasty, large amounts of donor skin will be taken from other areas of your body, such as your forearm, calf or lower abdomen. This can cause significant scarring. The skin will be rolled into the shape of a penis and anchored into position above your clitoris. You might also have:

• Urethral lengthening to allow for urination through your penis
• Grafting of nerves and blood vessels to provide sensation in your penis
• A procedure to sculpt the head of your penis (glansoplasty)
• Medical tattooing to create a distinct difference between the head and shaft of your penis

After phalloplasty, you'll have a tube (catheter) placed in your urethra to collect urine. You'll likely need to stay in the hospital for a few days. Phalloplasty carries a high rate of complications and might require many follow-up surgeries. Depending on the procedures done, recovery might take up to 12 weeks. Your new penis will not be able to become erect with sexual stimulation. A penile implant will be needed to allow penetrative sexual intercourse.

Scrotoplasty

Scrotoplasty is the surgical creation of a scrotum. During scrotoplasty, egg-shaped silicone testicular implants are inserted into your labia. To prepare for the procedure, you'll have expanders placed under the skin in your labia. The expanders will be gradually filled with saline through an external port over a period of months. When your skin has been expanded enough, your surgeon will insert the implants.

Some people find the implants uncomfortable. It's possible for the implants to wear through surrounding tissue or become infected.

What are the risks of masculinizing surgeries?

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

• Poor wound healing, such as along an incision line
• Fluid accumulation beneath the skin (seroma)
• A solid swelling of clotted blood within your tissues (hematoma)
• Changes in skin sensation such as persistent pain, tingling, reduced sensation or numbness
• Damaged or dead body tissue (tissue necrosis), such as in the nipple and in the surgically created penis (neophallus)
• A blood clot in a deep vein (deep vein thrombosis) or a blood clot in a lung (pulmonary embolism)
• An abnormal connection between two body parts (fistula), such as in the urinary tract
• Dissatisfaction with appearance after surgery
• Loss of sexual pleasure and functioning, including the persistent inability to achieve orgasm despite responding to sexual stimulation (anorgasmia)