Masculinizing gender-affirming surgery for transgender men or transmasculine non-binary people includes a variety of surgical procedures that alter anatomical traits to provide physical traits more comfortable to the trans man's male identity and functioning.
Chest reconstruction ("top surgery") is an important component of transition in the transmasculine population that can substantially improve gender incongruence.[1] This might be done as a step in the process of treating distress due to a difference between experienced or expressed gender and sex assigned at birth (gender dysphoria). The procedure can help transgender men transition physically to their self-affirmed gender. Surgeries for female-to-male transgender patients have similarities to both gynecomastia surgeries for cisgender men,[2]breast reduction surgery for gigantomastia, and the separate mastectomies done for breast cancer.[3] Top surgery involves more than a mastectomy for the treatment of breast cancer.[1] Special techniques are used to contour and reduce the chest wall, position the nipples and areola, and minimize scarring.[1]
If the breast size is small, surgery that spares the skin, nipple and areola (subcutaneous nipple-sparing mastectomy) may be performed. This procedure minimizes scarring, has a faster healing time and usually preserves sensation in the nipples. During this surgery, incisions are made around the borders of the areolae and the surrounding skin. Breast tissue is removed through the incisions and some skin also might be removed. Remaining skin is reattached at the border of the areola.[citation needed]
Research suggests that most transgender men are satisfied with their surgical results, with only 1% experiencing regret after the operation.[4]
Hysterectomy and bilateral salpingo-oophorectomy
Hysterectomy is a surgical procedure performed to remove the uterus. A total hysterectomy involves removal of the uterus and cervix, and a sub-partial hysterectomy involves removal of only the uterus. Bilateral salpingo-oophorectomy (BSO) is the removal of both ovaries and fallopian tubes.
According to the ACOG, symptomatic uterine leiomyomas are the most common indication for hysterectomy in the US, followed by abnormal uterine bleeding, endometriosis and prolapse.[5] Risk-reducing hysterectomy is also performed for patients with high-risk of endometrial cancer, including patients with germ-line BRCA1/2 mutations, Lynch Syndrome and family history. Hysterectomy can also be performed for male-identifying patients with uterus in conjunction with testosterone therapy.
Hysterectomy can be performed through three methods: abdominal, laparoscopic, vaginal.[6] Abdominal hysterectomy is performed with incision into the abdominal wall, whereas laparoscopic and vaginal hysterectomies are minimally invasive procedures.[7] Current ACOG guidelines recommend minimally invasive procedures, specifically vaginal hysterectomy, over surgical hysterectomy due to faster recovery time, shorter procedural time, shorter hospital stays and better quality of life.[7][8][9] Discharge from minimally invasive hysterectomy can occur as fast as one day post-operation, in contrast to five days post-operation for abdominal hysterectomies. Following discharge, patients often experience gastrointestinal symptoms such as constipation or urinary tract infections, as well as vaginal bleeding or discharge. These symptoms should be temporary and resolve within six weeks.[10] Follow-up visits with a gynecologist is recommended six-weeks following hysterectomy.
Follow-up care for male-identifying patients with uterus should still see a gynecologist for a check-up at least every three years. This is particularly the case for patients who:
retain their vagina (whether before or after further genital reconstruction,)
have a strong family history of cancers of the breast, ovary, or uterus (endometrium,)
have a personal history of gynecological cancer or significant dysplasia on a Pap smear.
develop vaginal bleeding post-operation and hormone therapy
Complications of hysterectomy involve infection, venous thromboembolic events, genitourinary and gastrointestinal tract injury and nerve injury. The most common of these complications is infection, which occurs at a rate of 10.5% of abdominal hysterectomy, 13% of vaginal hysterectomy and 9% of laparoscopic hysterectomy.[11] There is also a low risk of long-term complications, which can include chronic pain, sexual dysfunction and bowel dysfunction.
Genital reassignment
Also known as genital reconstructive procedures (GRT).[12]
Example of stage 1 female-to-male sex reassignment prior to glansplasty penis with tissue grafting scar on the left hip
Phalloplasty is the process of constructing a penis using a flap (graft) from the patient's arm, thigh, abdomen, or back.[13] Compared to metoidioplasty, phalloplasty provides a larger penis which may more closely resemble a natal penis.[medical citation needed] A neophallus created through phalloplasty relies on penile implants to achieve erection.[13] Sexual sensation varies in location and intensity, but is usually preserved at least at base of the penis, where the original clitoris was.[medical citation needed]
Example of completed metoidioplasty including neourethra and scrotoplasty, two years post-operation.
Metoidioplasty is done after enlarging the clitoris using hormone replacement therapy, where a neophallus is constructed from the enlarged clitoris, with or without extending the urethra to allow urination while standing up. The labia majora are united to form a scrotum, where prosthetic testicles can be inserted. The new neophallus ranges in size from 4–10cm (with an average of 5.7cm) and has the approximate girth of a human adult thumb.[15] Sexual sensation and erectile function are usually completely preserved. Specialized metoidioplasty penile implants may be an option in those who cannot achieve penetration during sex.[16]
Penile implants are usually used in phalloplasty surgery due to the inability of the neophallus to achieve proper erection. The penile implants are used in cisgender men to treat erectile dysfunction, and in transgender men during female-to-male sex reassignment surgery. Although the same penile implant has been used for both cisgender and transgender men, specialized penile implants for transgender men were recently developed by Zephyr Surgical Implants (Switzerland), in both inflatable and malleable models.[17] During phalloplasty, the tissue flap used to build the neophallus is wrapped around the implant either in the same surgery, or in separate surgeries. Penile implants are less commonly used in metoidioplasty due to how the process is done.
Facial masculinization
Facial masculinization also alters anatomical features to achieve an appearance that aligns more closely with gender identity. This can be achieved surgically, which might entail reconstruction of the forehead, nose, upper lip, or chin.[18] Non-surgical options include injections to alter the jawline and chin.[19] Non-surgical methods can be combined with surgery or used alone when subtle changes are desired. In addition to alteration of facial structure, hair transplantation can be used to achieve more permanent masculine hair growth patterns such as sideburns, mustaches, or beards.[19]
↑ Frey, Jordan D.; Poudrier, Grace; Chiodo, Michael V.; Hazen, Alexes (March 2017). "An Update on Genital Reconstruction Options for the Female-to-Male Transgender Patient: A Review of the Literature". Plastic and Reconstructive Surgery. 139 (3): 728–737. doi:10.1097/PRS.0000000000003062. ISSN1529-4242. PMID28234856.
↑ Metoidioplasty as a Single Stage Sex Reassignment Surgery in Female Transsexuals: Belgrade Experience Djordjevic, Miroslav L. et al., Journal of Sexual Medicine, Volume 6, Issue 5, 1306 - 1313
↑ Pigot, Garry L. S.; Sigurjónsson, Hannes; Ronkes, Brechje; Al-Tamimi, Muhammed; van der Sluis, Wouter B. (January 2020). "Surgical Experience and Outcomes of Implantation of the ZSI 100 FtM Malleable Penile Implant in Transgender Men After Phalloplasty". The Journal of Sexual Medicine. 17 (1): 152–158. doi:10.1016/j.jsxm.2019.09.019. ISSN1743-6109. PMID31680006. S2CID207890601.
Breast reconstruction is the surgical process of rebuilding the shape and look of a breast, most commonly in women who have had surgery to treat breast cancer. It involves using autologous tissue, prosthetic implants, or a combination of both with the goal of reconstructing a natural-looking breast. This process often also includes the rebuilding of the nipple and areola, known as nipple-areola complex (NAC) reconstruction, as one of the final stages.
Mastectomy is the medical term for the surgical removal of one or both breasts, partially or completely. A mastectomy is usually carried out to treat breast cancer. In some cases, women believed to be at high risk of breast cancer have the operation as a preventive measure. Alternatively, some women can choose to have a wide local excision, also known as a lumpectomy, an operation in which a small volume of breast tissue containing the tumor and a surrounding margin of healthy tissue is removed to conserve the breast. Both mastectomy and lumpectomy are referred to as "local therapies" for breast cancer, targeting the area of the tumor, as opposed to systemic therapies, such as chemotherapy, hormonal therapy, or immunotherapy.
Gender-affirming surgery (GAS) is a surgical procedure, or series of procedures, that alters a person's physical appearance and sexual characteristics to resemble those associated with their identified gender. The phrase is most often associated with transgender health care and intersex medical interventions, though many such treatments are also pursued by cisgender and non-intersex persons. It is also known as sex reassignment surgery (SRS), gender confirmation surgery (GCS), and several other names.
Facial feminization surgery (FFS) is a set of reconstructive surgical procedures that alter typically male facial features to bring them closer in shape and size to typical female facial features. FFS can include various bony and soft tissue procedures such as brow lift, rhinoplasty, cheek implantation, and lip augmentation.
Hysterectomy is the surgical removal of the uterus and cervix. Supracervical hysterectomy refers to removal of the uterus while the cervix is spared. These procedures may also involve removal of the ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures. The term “partial” or “total” hysterectomy are lay-terms that incorrectly describe the addition or omission of oophorectomy at the time of hysterectomy. These procedures are usually performed by a gynecologist. Removal of the uterus renders the patient unable to bear children and has surgical risks as well as long-term effects, so the surgery is normally recommended only when other treatment options are not available or have failed. It is the second most commonly performed gynecological surgical procedure, after cesarean section, in the United States. Nearly 68 percent were performed for conditions such as endometriosis, irregular bleeding, and uterine fibroids. It is expected that the frequency of hysterectomies for non-malignant indications will continue to fall given the development of alternative treatment options.
Phalloplasty is the construction or reconstruction of a penis or the artificial modification of the penis by surgery. The term is also occasionally used to refer to penis enlargement.
Metoidioplasty, metaoidioplasty, or metaidoioplasty is a female-to-male gender-affirming surgery.
Feminizing Gender-affirming surgery for transgender women or transfeminine non-binary people describes a variety of surgical procedures that alter the body to provide physical traits more comfortable and affirming to an individual's gender identity and overall functioning.
Gender transition is the process of affirming and expressing one's internal sense of gender, rather than the gender assigned to them at birth. It is the recommended course of treatment for individuals struggling with gender dysphoria, providing improved mental health outcomes in the majority of people.
Vaginoplasty is any surgical procedure that results in the construction or reconstruction of the vagina. It is a type of genitoplasty. Pelvic organ prolapse is often treated with one or more surgeries to repair the vagina. Sometimes a vaginoplasty is needed following the treatment or removal of malignant growths or abscesses to restore a normal vaginal structure and function. Surgery to the vagina is done to correct congenital defects to the vagina, urethra and rectum. It may correct protrusion of the urinary bladder into the vagina (cystocele) and protrusion of the rectum (rectocele) into the vagina. Often, a vaginoplasty is performed to repair the vagina and its attached structures due to trauma or injury.
Genital reconstructive surgery may refer to:
Scrotoplasty, also known as oscheoplasty, is a type of surgery to create or repair the scrotum. Scientific research for male genital plastic surgery such as scrotoplasty began to develop in the early 1900s. The development of testicular implants began in 1940 made from materials outside of what is used today. Today, testicular implants are created from saline or gel filled silicone rubber. There are a variety of reasons why scrotoplasty is done. Some transgender men and intersex or non-binary people who were assigned female at birth may choose to have this surgery to create a scrotum, as part of their transition. Other reasons for this procedure include addressing issues with the scrotum due to birth defects, aging, or medical conditions such as infection. For newborn males with penoscrotal defects such as webbed penis, a condition in which the penile shaft is attached to the scrotum, scrotoplasty can be performed to restore normal appearance and function. For older male adults, the scrotum may extend with age. Scrotoplasty or scrotal lift can be performed to remove the loose, excess skin. Scrotoplasty can also be performed for males who undergo infection, necrosis, traumatic injury of the scrotum.
Vaginectomy is a surgery to remove all or part of the vagina. It is one form of treatment for individuals with vaginal cancer or rectal cancer that is used to remove tissue with cancerous cells. It can also be used in gender-affirming surgery. Some people born with a vagina who identify as trans men or as nonbinary may choose vaginectomy in conjunction with other surgeries to make the clitoris more penis-like (metoidioplasty), construct of a full-size penis (phalloplasty), or create a relatively smooth, featureless genital area.
Chest reconstruction refers to any of various surgical procedures to reconstruct the chest by removing breast tissue or altering the nipples and areolae in order to mitigate gender dysphoria. Chest reconstruction may be performed in cases of gynecomastia and gender dysphoria. People may pursue chest reconstruction, also known as top surgery, as part of transitioning.
A penile implant is an implanted device intended for the treatment of erectile dysfunction, Peyronie's disease, ischemic priapism, deformity and any traumatic injury of the penis, and for phalloplasty or metoidioplasty, including in gender-affirming surgery. Men also opt for penile implants for aesthetic purposes. Men's satisfaction and sexual function is influenced by discomfort over genital size which leads to seek surgical and non-surgical solutions for penis alteration. Although there are many distinct types of implants, most fall into one of two categories: malleable and inflatable transplants.
Penis removal is the act of removing the human penis. It is not to be confused with the related practice of castration, in which the testicles are removed or deactivated, or emasculation, which removes both. Penis removal and castration have been used to create a class of servants or slaves called eunuchs in many different places and eras, having a notable presence in various societies such as Imperial China.
Genital leiomyomas are leiomyomas that originate in the dartos muscles, or smooth muscles, of the genitalia, areola, and nipple. They are a subtype of cutaneous leiomyomas that affect smooth muscle found in the scrotum, labia, or nipple. They are benign tumors, but may cause pain and discomfort to patients. Genital leiomyoma can be symptomatic or asymptomatic and is dependent on the type of leiomyoma. In most cases, pain in the affected area or region is most common. For vaginal leiomyoma, vaginal bleeding and pain may occur. Uterine leiomyoma may exhibit pain in the area as well as painful bowel movement and/or sexual intercourse. Nipple pain, enlargement, and tenderness can be a symptom of nipple-areolar leiomyomas. Genital leiomyomas can be caused by multiple factors, one can be genetic mutations that affect hormones such as estrogen and progesterone. Moreover, risk factors to the development of genital leiomyomas include age, race, and gender. Ultrasound and imaging procedures are used to diagnose genital leiomyomas, while surgically removing the tumor is the most common treatment of these diseases. Case studies for nipple areolar, scrotal, and uterine leiomyoma were used, since there were not enough secondary resources to provide more evidence.
Transgender pregnancy is the gestation of one or more embryos or fetuses by transgender people. As of 2024, the possibility is restricted to those born with female reproductive systems. However, transition-related treatments may impact fertility. Transgender men and nonbinary people who are or wish to become pregnant face social, medical, legal, and psychological concerns. As uterus transplantations are currently experimental, and none have successfully been performed on trans women, they cannot become pregnant.
Miroslav L Djordjevic is a Serbian surgeon specializing in sex reassignment surgery, and an assistant professor of urology at the School of Medicine, University of Belgrade, Serbia.
Facial masculinization surgery (FMS) is a set of plastic surgery procedures that can transform the patient's face to exhibit typical masculine morphology. Cisgender men may elect to undergo these procedures, and in the context of transgender people, FMS is a type of facial gender confirmation surgery (FGCS), which also includes facial feminization surgery (FFS) for transgender women.
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