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Vaginoplasty: Male to Female (MTF) Genital Reconstructive Surgery

What is vaginoplasty.

Vaginoplasty is a surgical procedure during which surgeons remove the penis and testicles and create a functional vagina. This achieves resolution of gender dysphoria and allows for sexual activity with compatible genitalia. The highly sensitive skin and tissues from the penis are preserved and used to construct the vaginal lining and build a clitoris, resulting in genitals with appropriate sensations. Scrotal skin is used to increase the depth of the vaginal canal. Penile, scrotal and groin skin are refashioned to make the labia majora and minora, and the urethral opening is relocated to an appropriate female position. The final result is an anatomically congruent, aesthetically appealing, and functionally intact vagina. Unless there is a medical reason to do so, the prostate gland is not removed.

University Hospitals has the only reconstructive urology program in the region offering MTF vaginoplasty and other genital gender affirmation surgical procedures. Call 216-844-3009 to schedule a consultation.

Penile Inversion Technique for Vaginoplasty

Penile inversion is the most common type of vaginoplasty and is considered the gold standard for male to female genital reconstruction. This type of gender affirmation surgery can last from two to five hours and is performed with the patient under general anesthesia.

The skin is removed from the penis and inverted to form a pouch which is then inserted into the vaginal cavity created between the urethra and rectum. The urethra is partially removed, shortened and repositioned. Labia majora and labia minora (outer and inner lips), and a clitoris are created. After everything has been sutured in place, a catheter is inserted into the urethra and the area is bandaged. The bandages and catheter will typically remain in place for four to five days. For some patients, a shallow depth vaginoplasty is recommended. This allows for a functional vagina but removes the need for vaginal dilation and douching.

Outcomes after vaginoplasty are excellent, and patients can expect to have aesthetic outcomes and sexual functionality similar to that for cis-women (people that were assigned female sex characteristics at birth and identify as female).

Complications after vaginoplasty are rare, but patients are advised to talk to their doctor about postsurgical risks and how to best manage them.

Things to Consider Before Having a Penile Inversion Vaginoplasty

• Given that the skin used to construct the new vaginal lining may have abundant hair follicles, patients are recommended to undergo hair removal (either electrolysis or laser hair removal) prior to the vaginoplasty procedure to eliminate the potential for vaginal hair growth. A full course of hair removal can take several months.
• Patients with fertility concerns should talk to their doctor about ways to save and preserve their sperm before having a vaginoplasty.
• It is always recommended that patients talk with a therapist in the months leading up to surgery to ensure they are mentally prepared for the transition.
• In accordance with the World Professional Association of Transgender Health (WPATH) standards of care, patients are required be on appropriate cross-gender hormone therapy for a year, live in the gender-congruent role for a year, and have 2 mental health letters endorsing their suitability for surgery.

Postoperative Care of Your New Vagina

To ensure that your newly constructed vagina maintains the desired depth and width, your UH surgeon  will give you a vaginal dilator to begin using as soon as the bandages are removed. Use the dilator regularly according to your surgeon’s recommendations. This will usually involve inserting the device for ten minutes several times per day for the first three months. After that, once per day for three months followed by two to three times a week until a full year has passed.

Furthermore, regular douching and cleaning of the vagina is recommended. Your surgeon will give you general guidelines for this as well. Approximately 1 out of 10 people who have a vaginoplasty end up requiring a second, minor surgery to correct some of the scarring from the first surgery and improve the function and cosmetic appearance.

Most genital gender affirmation surgeries are covered by insurance. In cases where they are not, your surgeon’s office will guide you through the self-pay options.

• Patient Care & Health Information
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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 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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• 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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What to Know About Metoidioplasty (Bottom Surgery)

• Who Qualifies?
• Surgical Techniques
• Neophallus Function
• Surgery Follow-Up
• Where to Have Surgery

Metoidioplasty , or "bottom surgery," is a gender-affirming surgical procedure that involves creating a neophallus (new penis) from a hormonally enlarged clitoris . Transgender men and transmasculine people assigned female at birth (AFAB) may elect for a metoidioplasty if they want their genital appearance to align with their gender identity.

In contrast to the more complex  phalloplasty  that involves several surgeries, metoidioplasty offers a more straightforward phallic reconstruction in one procedure.

During a metoidioplasty, a surgeon cuts the ligaments that connect the clitoris to the pubic bone to release the clitoris and create a penis with erogenous (sexual) sensations. It may also include additional steps, such as urethral lengthening and scrotoplasty (forming a scrotum), to enhance the appearance and functionality of the neophallus. 

This article explores metoidioplasty surgical techniques, the recovery process, and what to expect post-surgery. 

CarlosDavid.org / Getty Images

Who Qualifies for Metoidioplasty Surgery?

Metoidioplasty is a gender-affirming (sex-reassignment) surgery for transgender men assigned female at birth. According to the 2015 U.S. Transgender Survey, about 4% of trans men have undergone the procedure, while another 53% expressed a desire to undergo metoidioplasty in the future.

The World Professional Association for Transgender Health (WPATH) developed the criteria for gender reaffirmation surgeries to ensure optimal physical and psychological outcomes for those pursuing bottom (genital) surgeries. The eligibility criteria for metoidioplasty include the following:

• Ongoing and well-documented gender dysphoria  
• The ability to make informed decisions and provide consent for treatment
• Being 18 years of age or older
• Medical or mental health concerns are well-managed (if applicable)
• At least 12 consecutive months of gender-affirming testosterone therapy 
• Living as a male or masculine-presenting person for at least one year in all settings (e.g., work, school, with family members and community)

Though it is not required, regular visits with a mental health or other medical professional are highly recommended before undergoing a metoidioplasty. 

Metoidioplasty Surgical Techniques

People can choose a few different metoidioplasty surgical techniques depending on their preferences. Other procedures can occur simultaneously (e.g., hysterectomy) if desired. 

Simple Release Metoidioplasty 

In the simple release procedure, ligaments attached to the pubic bone are cut and released, and the clitoris is separated from surrounding tissue to enhance the position and visibility of the clitoris. The labia minora are wrapped around the clitoris to create the glans (head) of the newly formed penis.

Ring Metoidioplasty 

Similar to the simple release, this technique involves releasing the clitoral ligaments to lengthen the clitoris. This procedure also involves lengthening the urethra using a flap of tissue from the vaginal wall and labia minora. This procedure gives trans men a micropenis with more girth and the ability to stand while urinating.

Belgrade (Full) Metoidioplasty 

The Belgrade technique, or full metoidioplasty, involves the removal of the vagina (vaginectomy) and releasing the clitoris to lengthen and straighten the clitoris. The urethra is lengthened using vaginal tissue and buccal mucosa (inner cheek) skin grafts. The penis is reconstructed with the remaining clitoral and labial skin to give it more girth.

Then, the labia minor flaps are joined to create a scrotum (scrotoplasty), and testicular implants may be inserted into the newly created scrotum. A penile pump or vacuum is recommended three weeks post-surgery to lengthen the neophallus and prevent retraction.

Simultaneous Procedures 

In addition to metoidioplasty, some trans men may opt for additional procedures performed at the same time to achieve their desired outcomes. These procedures may include:

• Hysterectomy : Removal of the uterus 
• Bilateral salpingo-oophorectomy : Removal of the ovaries and fallopian tubes
• Vaginectomy : Removal of the vagina and surrounding tissues
• Scrotoplasty :   Forms a new scrotum; testicular implants may be placed to give the appearance of natural testicles
• Erectile implant : A device is placed inside the neophallus to help achieve erections

Metoidioplasty vs. Phalloplasty

Metoidioplasty and phalloplasty are surgical options for transgender men seeking gender-affirming genital reconstruction. Metoidioplasty involves using existing genital tissue, such as the hormonally enlarged clitoris, to create a neophallus. It usually results in a smaller but functional neophallus.

Phalloplasty involves constructing a neophallus using various techniques, including grafting tissue from other body parts. This procedure can provide a larger and more visually realistic phallus but is more complex and may require multiple stages. The choice between metoidioplasty and phalloplasty depends on individual preferences, desired outcomes, and considerations such as surgical risk, recovery time, and aesthetic goals.

Risks to Understand Before Metoidioplasty 

While metoidioplasty is generally considered safe, like any surgical intervention, it carries certain risks. Before undergoing metoidioplasty, discuss the risks with a healthcare provider to gain a comprehensive understanding and make an informed decision. 

Potential risks include:

• Urethral stricture or stenosis : Narrowing of the urethral passage, leading to difficulty with urination and potential obstruction of urine flow. Sometimes, urine flow may be blocked entirely, requiring surgery to correct the problem.
• Urethral fistula : An abnormal connection or passageway between the urethra and the skin or surrounding tissues. This can result in urine leakage or an abnormal opening along the neophallus. 
• Sensation changes :   The newly formed penis may have decreased or loss of sensation or feel hypersensitive and tender. 

Function of Neophallus Post-Bottom Surgery

Trans men who have undergone metoidioplasty report high levels of satisfaction with the procedure's results, both in appearance and function.

While a neophallus created through metoidioplasty is usually considered a micropenis (1–4 inches), erections and orgasms are achieved by nearly all who have undergone the procedure. Penetrative sex may or may not be possible. Urinating while standing is possible for most men after metoidioplasty.

Metoidioplasty Recovery Period 

The recovery period following metoidioplasty depends on the specific surgical technique and can vary from person to person. Most people can expect one week of bed rest immediately following the procedure and gradually resume their activities within about six weeks. 

Initially, there will be discomfort, swelling, and bleeding in the genital region, which will gradually subside over time. You may also experience:

• Bruising in the genital area that spreads from the belly down to the legs 
• Itching and short, sharp, shooting sensations as the area heals 
• Numbness at or near the incision sites, which can persist for months 
• Scarring on the genitals that will first appear red or pink and fade over time 

Metoidioplasty Follow-Up (and Asking for Help)

You will need assistance and support during the follow-up period after metoidioplasty, as the recovery process can involve discomfort, limited mobility, and restricted activity. You will need a caretaker for at least a week or two after the procedure—someone who can help with daily tasks such as meal preparation, household chores, and running errands.

Your surgeon may restrict certain activities, such as driving, sex, and heavy lifting. You may need help with transportation to follow-up appointments for about six weeks. Most people can resume their normal activities within six weeks post-surgery. Still, getting the OK from a healthcare provider is important to ensure you are properly healed and to lower the risk of complications. 

Where to Have Metoidioplasty Surgery

Specialized surgeons with experience in transgender healthcare often perform metoidioplasty surgery. The procedure is usually carried out in a hospital or surgical center with the necessary tools and equipment for the surgery. It is essential to choose a reputable medical facility that is experienced in transgender surgeries and maintains a supportive and inclusive environment.

When considering where to have metoidioplasty surgery, start by asking a mental health professional or another healthcare provider for referrals and recommendations of surgeons who specialize in the procedure. They can provide information and guidance on the options available to you. 

Researching and gathering information about the surgeon's qualifications, experience, and success rates, as well as reading reviews or testimonials from other people who have undergone metoidioplasty at the facility, can also help you select the most suitable location for the surgery. Open communication with healthcare providers can ensure that all your questions and concerns are addressed before deciding where to have metoidioplasty surgery.

Metoidioplasty is a gender-affirming surgery for trans-male people assigned female at birth (AFAB). The procedure involves releasing the clitoral ligaments and utilizing the hormonally enlarged clitoris to create a neophallus (new penis).

There are a few different metoidioplasty techniques. Sometimes, people undergo simultaneous procedures, such as hysterectomy and vaginectomy. Metoidioplasty is considered a safe, effective procedure that results in a 1–4 inch functional penis that gives trans men the opportunity to align their physical characteristics with their gender identity. 

Djordjevic ML, Stojanovic B, Bizic M. Metoidioplasty: Techniques and outcomes . Transl Androl Urol . 2019;8(3):248-253. doi:10.21037/tau.2019.06.12

Kjölhede A, Cornelius F, Huss F, Kratz G. Metoidioplasty and groin flap phalloplasty as two surgical methods for the creation of a neophallus in female-to-male gender-confirming surgery: A retrospective study comprising 123 operated patients . JPRAS Open . 2019;22:1-8. doi:10.1016/j.jpra.2019.07.003

Stojanovic B, Bencic M, Bizic M, Djordjevic ML. Metoidioplasty in gender affirmation: A review . Indian J Plast Surg . 2022;55(2):156-161. doi:10.1055/s-0041-1740081

National Center for Transgender Equality. Injustice at every turn: a report of the national transgender discrimination survey .

The World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people .

Heston AL, Esmonde NO, Dugi DD 3rd, Berli JU. Phalloplasty: techniques and outcomes .  Transl Androl Urol . 2019;8(3):254-265. doi:10.21037/tau.2019.05.05

Alberta Medical Association. Metoidioplasty .

Bordas N, Stojanovic B, Bizic M, et al. Metoidioplasty: Surgical options and outcomes in 813 cases . Front Endocrinol (Lausanne) . 2021;12:760284. doi:10.3389/fendo.2021.760284

TransCare BC. Provincial Health Services Authority. Metoidioplasty .

Michigan Medicine: University of Michigan. What to expect: Metoidioplasty at Michigan Medicine .

TransHealthCare. Metoidioplasty - list of surgeons in the USA .

By Lindsay Curtis Curtis is a writer with over 20 years of experience focused on mental health, sexual health, cancer care, and spinal health.

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What Is Gender Affirmation Surgery?

A gender affirmation surgery allows individuals, such as those who identify as transgender or nonbinary, to change one or more of their sex characteristics. This type of procedure offers a person the opportunity to have features that align with their gender identity.

For example, this type of surgery may be a transgender surgery like a male-to-female or female-to-male surgery. Read on to learn more about what masculinizing, feminizing, and gender-nullification surgeries may involve, including potential risks and complications.

Why Is Gender Affirmation Surgery Performed?

A person may have gender affirmation surgery for different reasons. They may choose to have the surgery so their physical features and functional ability align more closely with their gender identity.

For example, one study found that 48,019 people underwent gender affirmation surgeries between 2016 and 2020. Most procedures were breast- and chest-related, while the remaining procedures concerned genital reconstruction or facial and cosmetic procedures.

In some cases, surgery may be medically necessary to treat dysphoria. Dysphoria refers to the distress that transgender people may experience when their gender identity doesn't match their sex assigned at birth. One study found that people with gender dysphoria who had gender affirmation surgeries experienced:

• Decreased antidepressant use
• Decreased anxiety, depression, and suicidal ideation
• Decreased alcohol and drug abuse

However, these surgeries are only performed if appropriate for a person's case. The appropriateness comes about as a result of consultations with mental health professionals and healthcare providers.

Transgender vs Nonbinary

Transgender and nonbinary people can get gender affirmation surgeries. However, there are some key ways that these gender identities differ.

Transgender is a term that refers to people who have gender identities that aren't the same as their assigned sex at birth. Identifying as nonbinary means that a person doesn't identify only as a man or a woman. A nonbinary individual may consider themselves to be:

• Both a man and a woman
• Neither a man nor a woman
• An identity between or beyond a man or a woman

Hormone Therapy

Gender-affirming hormone therapy uses sex hormones and hormone blockers to help align the person's physical appearance with their gender identity. For example, some people may take masculinizing hormones.

"They start growing hair, their voice deepens, they get more muscle mass," Heidi Wittenberg, MD , medical director of the Gender Institute at Saint Francis Memorial Hospital in San Francisco and director of MoZaic Care Inc., which specializes in gender-related genital, urinary, and pelvic surgeries, told Health .

Types of hormone therapy include:

• Masculinizing hormone therapy uses testosterone. This helps to suppress the menstrual cycle, grow facial and body hair, increase muscle mass, and promote other male secondary sex characteristics.
• Feminizing hormone therapy includes estrogens and testosterone blockers. These medications promote breast growth, slow the growth of body and facial hair, increase body fat, shrink the testicles, and decrease erectile function.
• Non-binary hormone therapy is typically tailored to the individual and may include female or male sex hormones and/or hormone blockers.

It can include oral or topical medications, injections, a patch you wear on your skin, or a drug implant. The therapy is also typically recommended before gender affirmation surgery unless hormone therapy is medically contraindicated or not desired by the individual.

Masculinizing Surgeries

Masculinizing surgeries can include top surgery, bottom surgery, or both. Common trans male surgeries include:

• Chest masculinization (breast tissue removal and areola and nipple repositioning/reshaping)
• Hysterectomy (uterus removal)
• Metoidioplasty (lengthening the clitoris and possibly extending the urethra)
• Oophorectomy (ovary removal)
• Phalloplasty (surgery to create a penis)
• Scrotoplasty (surgery to create a scrotum)

Top Surgery

Chest masculinization surgery, or top surgery, often involves removing breast tissue and reshaping the areola and nipple. There are two main types of chest masculinization surgeries:

• Double-incision approach : Used to remove moderate to large amounts of breast tissue, this surgery involves two horizontal incisions below the breast to remove breast tissue and accentuate the contours of pectoral muscles. The nipples and areolas are removed and, in many cases, resized, reshaped, and replaced.
• Short scar top surgery : For people with smaller breasts and firm skin, the procedure involves a small incision along the lower half of the areola to remove breast tissue. The nipple and areola may be resized before closing the incision.

Metoidioplasty

Some trans men elect to do metoidioplasty, also called a meta, which involves lengthening the clitoris to create a small penis. Both a penis and a clitoris are made of the same type of tissue and experience similar sensations.

Before metoidioplasty, testosterone therapy may be used to enlarge the clitoris. The procedure can be completed in one surgery, which may also include:

• Constructing a glans (head) to look more like a penis
• Extending the urethra (the tube urine passes through), which allows the person to urinate while standing
• Creating a scrotum (scrotoplasty) from labia majora tissue

Phalloplasty

Other trans men opt for phalloplasty to give them a phallic structure (penis) with sensation. Phalloplasty typically requires several procedures but results in a larger penis than metoidioplasty.

The first and most challenging step is to harvest tissue from another part of the body, often the forearm or back, along with an artery and vein or two, to create the phallus, Nicholas Kim, MD, assistant professor in the division of plastic and reconstructive surgery in the department of surgery at the University of Minnesota Medical School in Minneapolis, told Health .

Those structures are reconnected under an operative microscope using very fine sutures—"thinner than our hair," said Dr. Kim. That surgery alone can take six to eight hours, he added.

In a separate operation, called urethral reconstruction, the surgeons connect the urinary system to the new structure so that urine can pass through it, said Dr. Kim. Urethral reconstruction, however, has a high rate of complications, which include fistulas or strictures.

According to Dr. Kim, some trans men prefer to skip that step, especially if standing to urinate is not a priority. People who want to have penetrative sex will also need prosthesis implant surgery.

Hysterectomy and Oophorectomy

Masculinizing surgery often includes the removal of the uterus (hysterectomy) and ovaries (oophorectomy). People may want a hysterectomy to address their dysphoria, said Dr. Wittenberg, and it may be necessary if their gender-affirming surgery involves removing the vagina.

Many also opt for an oophorectomy to remove the ovaries, almond-shaped organs on either side of the uterus that contain eggs and produce female sex hormones. In this case, oocytes (eggs) can be extracted and stored for a future surrogate pregnancy, if desired. However, this is a highly personal decision, and some trans men choose to keep their uterus to preserve fertility.

Feminizing Surgeries

Surgeries are often used to feminize facial features, enhance breast size and shape, reduce the size of an Adam’s apple , and reconstruct genitals.  Feminizing surgeries can include: 

• Breast augmentation
• Facial feminization surgery
• Penis removal (penectomy)
• Scrotum removal (scrotectomy)
• Testicle removal (orchiectomy)
• Tracheal shave (chondrolaryngoplasty) to reduce an Adam's apple
• Vaginoplasty
• Voice feminization

Breast Augmentation

Top surgery, also known as breast augmentation or breast mammoplasty, is often used to increase breast size for a more feminine appearance. The procedure can involve placing breast implants, tissue expanders, or fat from other parts of the body under the chest tissue.

Breast augmentation can significantly improve gender dysphoria. Studies show most people who undergo top surgery are happier, more satisfied with their chest, and would undergo the surgery again.

Most surgeons recommend 12 months of feminizing hormone therapy before breast augmentation. Since hormone therapy itself can lead to breast tissue development, transgender women may or may not decide to have surgical breast augmentation.

Facial Feminization and Adam's Apple Removal

Facial feminization surgery (FFS) is a series of plastic surgery procedures that reshape the forehead, hairline, eyebrows, nose, cheeks, and jawline. Nonsurgical treatments like cosmetic fillers, botox, fat grafting, and liposuction may also be used to create a more feminine appearance.  

Some trans women opt for chondrolaryngoplasty, also known as a tracheal shave. The procedure reduces the size of the Adam's apple, an area of cartilage around the larynx (voice box) that tends to be larger in people assigned male at birth.

Vulvoplasty and Vaginoplasty

As for bottom surgery, there are various feminizing procedures from which to choose. Vulvoplasty (to create external genitalia without a vagina) or vaginoplasty (to create a vulva and vaginal canal) are two of the most common procedures.

Dr. Wittenberg noted that people might undergo six to 12 months of electrolysis or laser hair removal before surgery to remove pubic hair from the skin that will be used for the vaginal lining.

Surgeons have different techniques for creating a vaginal canal. A common one is a penile inversion, where the masculine structures are emptied and inverted into a created cavity, explained Dr. Kim. Vaginoplasty may be done in one or two stages, said Dr. Wittenberg, and the initial recovery is three months—but it will be a full year until people see results.

Surgical removal of the penis or penectomy is sometimes used in feminization treatment. This can be performed along with an orchiectomy and scrotectomy.

However, a total penectomy is not commonly used in feminizing surgeries . Instead, many people opt for penile-inversion surgery, a technique that hollows out the penis and repurposes the tissue to create a vagina during vaginoplasty.

Orchiectomy and Scrotectomy

An orchiectomy is a surgery to remove the testicles —male reproductive organs that produce sperm. Scrotectomy is surgery to remove the scrotum, that sac just below the penis that holds the testicles.

However, some people opt to retain the scrotum. Scrotum skin can be used in vulvoplasty or vaginoplasty, surgeries to construct a vulva or vagina.

Other Surgical Options

Some gender non-conforming people opt for other types of surgeries. This can include:

• Gender nullification procedures
• Penile preservation vaginoplasty
• Vaginal preservation phalloplasty

Gender Nullification

People who are agender or asexual may opt for gender nullification, sometimes called nullo. This involves the removal of all sex organs. The external genitalia is removed, leaving an opening for urine to pass and creating a smooth transition from the abdomen to the groin.

Depending on the person's sex assigned at birth, nullification surgeries can include:

• Breast tissue removal
• Nipple and areola augmentation or removal

Penile Preservation Vaginoplasty

Some gender non-conforming people assigned male at birth want a vagina but also want to preserve their penis, said Dr. Wittenberg. Often, that involves taking skin from the lining of the abdomen to create a vagina with full depth.

Vaginal Preservation Phalloplasty

Alternatively, a patient assigned female at birth can undergo phalloplasty (surgery to create a penis) and retain the vaginal opening. Known as vaginal preservation phalloplasty, it is often used as a way to resolve gender dysphoria while retaining fertility.

The recovery time for a gender affirmation surgery will depend on the type of surgery performed. For example, healing for facial surgeries may last for weeks, while transmasculine bottom surgery healing may take months.

Your recovery process may also include additional treatments or therapies. Mental health support and pelvic floor physiotherapy are a few options that may be needed or desired during recovery.

Risks and Complications

The risk and complications of gender affirmation surgeries will vary depending on which surgeries you have. Common risks across procedures could include:

• Anesthesia risks
• Hematoma, which is bad bruising
• Poor incision healing

Complications from these procedures may be:

• Acute kidney injury
• Blood transfusion
• Deep vein thrombosis, which is blood clot formation
• Pulmonary embolism, blood vessel blockage for vessels going to the lung
• Rectovaginal fistula, which is a connection between two body parts—in this case, the rectum and vagina
• Surgical site infection
• Urethral stricture or stenosis, which is when the urethra narrows
• Urinary tract infection (UTI)
• Wound disruption

What To Consider

It's important to note that an individual does not need surgery to transition. If the person has surgery, it is usually only one part of the transition process.

There's also psychotherapy . People may find it helpful to work through the negative mental health effects of dysphoria. Typically, people seeking gender affirmation surgery must be evaluated by a qualified mental health professional to obtain a referral.

Some people may find that living in their preferred gender is all that's needed to ease their dysphoria. Doing so for one full year prior is a prerequisite for many surgeries.

All in all, the entire transition process—living as your identified gender, obtaining mental health referrals, getting insurance approvals, taking hormones, going through hair removal, and having various surgeries—can take years, healthcare providers explained.

A Quick Review

Whether you're in the process of transitioning or supporting someone who is, it's important to be informed about gender affirmation surgeries. Gender affirmation procedures often involve multiple surgeries, which can be masculinizing, feminizing, or gender-nullifying in nature.

It is a highly personalized process that looks different for each person and can often take several months or years. The procedures also vary regarding risks and complications, so consultations with healthcare providers and mental health professionals are essential before having these procedures.

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Djordjevic ML, Stojanovic B, Bizic M. Metoidioplasty: techniques and outcomes . Transl Androl Urol . 2019;8(3):248–53. doi:10.21037/tau.2019.06.12

Bordas N, Stojanovic B, Bizic M, Szanto A, Djordjevic ML. Metoidioplasty: surgical options and outcomes in 813 cases .  Front Endocrinol . 2021;12:760284. doi:10.3389/fendo.2021.760284

Al-Tamimi M, Pigot GL, van der Sluis WB, et al. The surgical techniques and outcomes of secondary phalloplasty after metoidioplasty in transgender men: an international, multi-center case series .  The Journal of Sexual Medicine . 2019;16(11):1849-1859. doi:10.1016/j.jsxm.2019.07.027

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Phalloplasty for Gender Affirmation

Featured Expert:

Fan Liang, M.D.

Phalloplasty is surgery for masculinizing gender affirmation. Phalloplasty is a multistaged process that may include a variety of procedures, including:

• Creating the penis
• Lengthening the urethra so you are able to stand to urinate
• Creating the tip (glans) of the penis
• Creating the scrotum
• Removing the vagina, uterus and ovaries
• Placing erectile and testicular implants
• Skin grafting from the donor tissue site 

Gender affirmation surgery is customized to each individual. Your surgical plan may include more or fewer of these steps and procedures. Fan Liang, M.D. , medical director of the Center for Transgender and Gender Expansive Health at Johns Hopkins, explains what you should know.

Are there different types of phalloplasty?

Phalloplasty involves using skin flaps, which are areas of skin moved from one area of the body to another. The skin flap is then reshaped, contoured and reattached to the groin to create the penis. There are three approaches the surgeon may use to construct the penis, using skin from the arm (radial forearm free flap), leg (anterolateral thigh flap) or side (latissimus dorsi flap). 

There are pros and cons to each approach. Factors for choosing skin flap locations include the patient’s health and fat distribution, nerve function, blood flow and desired surgical outcomes.

What is a radial forearm free flap?

A radial forearm free flap (RFFF) involves taking the skin, fat, nerves, arteries and veins from your wrist to about halfway up your forearm to create the penis. Typically, the surgeon will use your nondominant hand so it is easier for you to recover and return to your day-to-day activities.

During your surgical consultation, the doctor will check the blood flow to your arm and hand noninvasively. This involves temporarily putting pressure on arteries then releasing the pressure to test blood distribution in the arm and hand.

There are three stages to this procedure.

• Stage 1: The first stage of an RFFF approach is creating the penis using tissue from the forearm. The area where the forearm tissue is taken will require a skin graft. This may occur at the time of the initial phalloplasty surgery, or it may occur three to five weeks afterward. If it occurs later, patients will have a temporary skin covering over the forearm to help it heal.
• Stage 2: The second stage, scheduled about five to six months later, may include lengthening the urethra to allow for urination out of the tip of the penis, creating the scrotum and removing the vagina, and other procedures depending on the patient’s individualized plan.
• Stage 3: The third stage of surgery involves putting in place testicle implants and an erectile device to help the patient achieve an erection. The third stage typically takes place 12 months after the second.

Will I have a say in how the phalloplasty is staged and the surgical plan?

Your gender affirmation surgery is highly personalized. Depending on what is most important to you, your surgery team will work with you on a customized plan beforehand. You and your surgeon will discuss your priorities and decide which procedures are right for you. Each stage will be scheduled to ensure your health and safety and provide the best chance of good results.

How long will I be in the hospital?

After your stage 1 surgery, you will stay as an inpatient for four to five days. Your surgical team will frequently monitor the blood supply to the tissue that has been used to create your new penis and ensure you are able to use the bathroom and walk around after surgery. Procedures for stages 2 and 3 do not require a hospital stay.

Will I need a catheter?

During your inpatient stay for stage 1 surgery, you will have a suprapubic tube that goes directly into your bladder and another catheter in your native urethra for at least five days. It is typically removed in the hospital before you go home.

If you decide not to have urethral lengthening as part of stage 2, you will have a Foley catheter placed in the operating room and removed before you leave the hospital. If you decide to have urethral lengthening, you will go home with a Foley catheter in the new urethra and a suprapubic tube. A clamp ensures that the urethra does not leak urine.

What is a suprapubic tube?

A suprapubic tube (SPT) allows urine to drain from your bladder. It is placed in the lower part of your abdomen, below the belly button. The SPT stays in for four to five weeks, depending on your healing and recovery.

When will my SPT be removed?

Before the SPT is removed, around four weeks after surgery, a urologist will perform a retrograde urethrogram. This involves putting dye into the bladder through the new urethra. An X-ray tracks the dye to see if the new urethra is open and ready for urination. If so, the doctor will clamp the SPT and you will be allowed to urinate from your new urethra. If everything looks good after a few days, the SPT is removed.

Forearm Flap Phalloplasty

Stage 1: phallus creation. Enlarged image .

Stage 2: urethral lengthening and scrotoplasty. Enlarged image .

Stage 3: penile prosthesis. Enlarged image .

Other Skin Flaps Used in Phalloplasty

What is an anterolateral thigh flap.

An anterolateral thigh flap (ALT) uses skin, fat, nerves, arteries and veins from the leg to create a penis.  A special vascular CT scan can help the surgeon  examine the blood supply of each leg to determine which leg will be better for creating the skin flap.

The stage of the ALT phalloplasty are similar to the RFFF. The area where the thigh tissue is taken will also require a skin graft. The resulting scar on the thigh can be covered with shorts.

What is a musculocutaneous latissimus dorsi flap?

A musculocutaneous latissimus dorsi skin flap (MLD) involves the skin, fat, nerves, arteries and veins from the side of your back to create a penis. The surgeon may order a special CT scan to look at the blood flow throughout the donor site area.

The stages of the MLD phalloplasty are similar to the RFFF and ALT. However, the area from which the back tissue is taken usually does not require a skin graft and can be closed in a straight line. The scar can be covered with a shirt. Patients may experience some initial weakness raising their arm, but this improves with time.

How is penis size determined?

Penis size depends on patient preferences and the skin flap harvested from your body. Thinner patients with less fat on the skin flap will have a penis with less girth. Alternatively, patients with a greater amount of fat will have a thicker penis.

The length of the penis depends on the patient’s donor site, but typically it is about 5–6 inches. After the first stage, the penis may decrease in size as postoperative swelling decreases and the tissue settles into its new location.

What determines scrotum size?

Scrotum size is specific to the patient and depends on the amount of skin that is present in the genital area before phalloplasty. The more genital tissue there is, the larger the scrotum and the testicular implants can be.

There are different ways to create the scrotum, including a procedure called V-Y scrotoplasty, a technique that creates a pouch to hold testicular implants. AART silicone round carving blocks have been approved by the FDA to be used as implants.

Procedures to Discuss with Your Physician Before Phalloplasty

Each individual undergoing gender confirmation surgery is different. Your surgeon will work with you to discuss which procedures, and their timing, are best for you and your goals.

Should I have a hysterectomy before phalloplasty surgery?

For those interested in this procedure,  hysterectomies  are typically done before phalloplasty and do not require a vaginectomy.

Urethral Lengthening Before Phalloplasty

If you choose to have urethral lengthening, this procedure involves lengthening your existing urethra so that you are able to urinate out of the tip of the penis. It involves connecting your current urethra to the new urethra created in the shaft of the penis.

Not all patients choose to have urethral lengthening; however, this will be a necessary step if you want to stand when you urinate. It is also important to know that if you decide not to have urethral lengthening in stage 1 of your phalloplasty, it will not be possible to have the lengthening procedure later.

Complications of Urethral Lengthening

The most common complications for urethral lengthening include urethral strictures (narrowed areas of the urethra), fistula (creation of a passageway between the urethra and another location) and diverticula (formation of a pouch in the urethra). This may require an additional surgical procedure to fix.

What is a metoidioplasty?

A metoidioplasty is a surgical procedure to achieve masculine-appearing genitalia with fewer steps than a phalloplasty. The skin of the labia and around the clitoris is lengthened to achieve the appearance of a penis. Some people prefer to undergo a metoidioplasty if they do not want to use tissue from their arms or legs to create a penis or if they prefer a shorter, more straightforward surgery.

A metoidioplasty procedure has a quicker recovery and fewer complications. Surgeons can discuss metoidioplasty with patients and help them decide if this option is right for them.

Will I need to have hair removal?

Yes, before surgery, after you consult with the surgical team and choose a skin flap site, you will get a template for hair removal that you can give to your hair removal professional.

What if I have a tattoo on my preferred donor site?

As long as there is good blood flow and nerve function, donor sites — even those with a tattoo — can be used.

Penile Function and Sensation After Phalloplasty

What can i do with a reconstructed penis.

Penis function is determined by what you and your surgery team agree on for your surgical plan. If it is important for you to urinate out of the tip of your penis, then urethral lengthening may be a good choice for you. If sensation is most important, your team will focus on a donor site with good nerve innervation. If penetrative sex is most important, and you would like to maintain an erection, then implanting an erectile prosthetic can be part of your surgery plan.

Can I get an erection after phalloplasty?

In stage 3 phalloplasty, a urologist can place a prosthetic erectile device which will allow you to maintain an erection. As of September 2022, no implantable prosthetic devices have been FDA-approved for phalloplasty. Instead, the surgeon can use a device intended for patients with erectile dysfunction to allow transmasculine patients to achieve an erection. There is a risk of infection and implant rejection with an erectile implant . If this happens, it may take six months before another device can be placed into the penis.

What kind of sensation and feeling can I expect?

Sensation recovery varies by patient. Nerve regeneration can begin as early as three weeks after surgery, but it can take longer in some patients. Sometimes sensation can take up to a year or longer. Return of nerve sensation is not guaranteed. As nerves regenerate and strengthen connections, you might experience shooting pain, tingling or electrical sensations. As time goes on, the tingling feeling begins to subside.

What is nerve hookup during phalloplasty?

Nerve hookup involves taking existing nerves from the donor site, such as the arm, and connecting them to nerves located in the pelvis. This allows you to have sensation in the reconstructed penis.

What is clitoral burying during phalloplasty surgery?

Clitoral burying involves moving the clitoris into the base of the penis to increase sensation. This is typically done at stage 2.

Is orgasm possible after phalloplasty?

Orgasm is possible after phalloplasty, especially if your surgery plan emphasizes preserving sensation. It is important to note that your penis will not ejaculate with semen at the time of orgasm.

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Gender Confirmation Surgery

The University of Michigan Health System offers procedures for surgical gender transition.  Working together, the surgical team of the Comprehensive Gender Services Program, which includes specialists in plastic surgery, urology and gynecology, bring expertise, experience and safety to procedures for our transgender patients.

Access to gender-related surgical procedures for patients is made through the University of Michigan Health System Comprehensive Gender Services Program .

The Comprehensive Gender Services Program adheres to the WPATH Standards of Care , including the requirement for a second-opinion prior to genital sex reassignment.

Available surgeries:

Male-to-Female:  Tracheal Shave  Breast Augmentation  Facial Feminization  Male-to-Female genital sex reassignment

Female-to-Male:  Hysterectomy, oophorectomy, vaginectomy Chest Reconstruction  Female-to-male genital sex reassignment

Sex Reassignment Surgeries (SRS)

At the University of Michigan Health System, we are dedicated to offering the safest proven surgical options for sex reassignment (SRS.)   Because sex reassignment surgery is just one step for transitioning people, the Comprehensive Gender Services Program has access to providers for mental health services, hormone therapy, pelvic floor physiotherapy, and speech therapy.  Surgical procedures are done by a team that includes, as appropriate, gynecologists, urologists, pelvic pain specialists and a reconstructive plastic surgeon. A multi-disciplinary team helps to best protect the health of the patient.

For patients receiving mental health and medical services within the University of Michigan Health System, the UMHS-CGSP will coordinate all care including surgical referrals.  For patients who have prepared for surgery elsewhere, the UMHS-CGSP will help organize the needed records, meet WPATH standards, and coordinate surgical referrals.  Surgical referrals are made through Sara Wiener the Comprehensive Gender Services Program Director.

Male-to-female sex reassignment surgery

At the University of Michigan, participants of the Comprehensive Gender Services Program who are ready for a male-to-female sex reassignment surgery will be offered a penile inversion vaginoplasty with a neurovascular neoclitoris.

During this procedure, a surgeon makes “like become like,” using parts of the original penis to create a sensate neo-vagina. The testicles are removed, a procedure called orchiectomy. The skin from the scrotum is used to make the labia. The erectile tissue of the penis is used to make the neoclitoris. The urethra is preserved and functional.

This procedure provides for aesthetic and functional female genitalia in one 4-5 hour operation.  The details of the procedure, the course of recovery, the expected outcomes, and the possible complications will be covered in detail during your surgical consultation. What to Expect: Vaginoplasty at Michigan Medicine .

Female-to-male sex reassignment

At the University of Michigan, participants of the Comprehensive Gender Services Program who are ready for a female-to-male sex reassignment surgery will be offered a phalloplasty, generally using the radial forearm flap method. 

This procedure, which can be done at the same time as a hysterectomy/vaginectomy, creates an aesthetically appropriate phallus and creates a urethera for standing urination.  Construction of a scrotum with testicular implants is done as a second stage.  The details of the procedure, the course of recovery, the expected outcomes, and the possible complications will be covered in detail during your surgical consultation.

Individuals who desire surgical procedures who have not been part of the Comprehensive Gender Services Program should contact the program office at (734) 998-2150 or email [email protected] . W e will assist you in obtaining what you need to qualify for surgery.

How Gender Reassignment Surgery Works (Infographic)

Bradley Manning, the U.S. Army private who was sentenced Aug. 21 to 35 years in a military prison for releasing highly sensitive U.S. military secrets, is seeking gender reassignment. Here’s how gender reassignment works:

Converting male anatomy to female anatomy requires removing the penis, reshaping genital tissue to appear more female and constructing a vagina.

An incision is made into the scrotum, and the flap of skin is pulled back. The testes are removed.

A shorter urethra is cut. The penis is removed, and the excess skin is used to create the labia and vagina.

People who have male-to-female gender-reassignment surgery retain a prostate. Following surgery, estrogen (a female hormone) will stimulate breast development, widen the hips, inhibit the growth of facial hair and slightly increase voice pitch.

Female-to-male surgery has achieved lesser success due to the difficulty of creating a functioning penis from the much smaller clitoral tissue available in the female genitals.

The uterus and the ovaries are removed. Genital reconstructive procedures (GRT) use either the clitoris, which is enlarged by hormones, or rely on free tissue grafts from the arm, the thigh or belly and an erectile prosthetic (phalloplasty).

Breasts need to be surgically altered if they are to look less feminine. This process involves removing breast tissue and excess skin, and reducing and properly positioning the nipples and areolae. Androgens (male hormones) will stimulate the development of facial and chest hair, and cause the voice to deepen.

Reliable statistics are extremely difficult to obtain. Many sexual-reassignment procedures are conducted in private facilities that are not subject to reporting requirements.

The cost for female-to-male reassignment can be more than $50,000. The cost for male-to-female reassignment can be $7,000 to $24,000.

Between 100 to 500 gender-reassignment procedures are conducted in the United States each year.

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Medindia » Articles » Procedure » FAQs on Gender-Reassignment Surgery: Everything You Need to Know

Gender-Reassignment Surgery: Everything You Need to Know

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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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Youth transgender care policies should be driven by science

U.s. states should follow europe’s example when deciding on medical care for minors experiencing gender dysphoria, by joshua cohen.

This article originally appeared on Undark.

I n the U.S., 23 states have passed legislation to ban medicalized care for minors with gender dysphoria, or the experience of distress that can occur when a person’s gender identity does not match the sex they were assigned at birth. On the other hand, 12 state legislatures have introduced laws to protect access to youth transgender care. Such care can include puberty blockers, which are medications that suppress the body's production of sex hormones, and cross-sex hormones like testosterone or estrogen that alter secondary sex characteristics. It also may include sexual reassignment surgery in rare instances.

U.S. policies on both ends of the spectrum are not science-driven but rather emanate from polar-opposite ideologies. Unlike in Europe, there doesn’t appear to be room for a non-ideological process for determining what the best care is that weighs the emerging clinical evidence and adjusts policies accordingly.

As reported in Axios , state efforts to restrict various forms of transgender medicine are being fueled by religious groups that aim to shape policy based on their strongly held beliefs around the immutability of gender and family.  Faith-based objections to transgender care come from a worldview in which God created humans as male or female. Here, the role of parents’ rights features prominently, as well as a conviction that adolescents are insufficiently mature to decide on trans alterations to their bodies. Moreover, lawmakers point out that some young people later regret having had irreversible body-altering treatment.

To take a more rational approach, the U.S. ought to adopt the European perspective and look to the forerunners in gender care — the Dutch.

The bans on care can be driven by extreme religious views. In one example, The Associated Press reported last year that Oklahoma state Sen. David Bullard introduced what he called the “Millstone Act” — a bill that would make the act of providing gender transition procedures to anyone under the age of 26 a felony — by citing a Bible passage that suggests those who cause children to sin should be drowned. The age limit was later lowered to 18.

Proponents, however, see the idea behind gender-affirming care as offering medical treatment so that a person can live as the gender with which they identify. A frequently heard argument is that children who can’t access care are at significantly higher risk of worse mental health outcomes. There is evidence that gender-affirming care for youth yields short-term improvements in terms of less depression and suicidality. However, a review of the literature shows it suffers from a lack of methodological rigor by not adequately controlling for the presence of other psychological conditions, substance use, and factors that enhance or reduce suicide risk. This greatly enhances the possibility of misinterpreting the data, leading researchers to cite significant differences between groups being compared when in fact there are no differences.

U.S. policies on both ends of the spectrum are not science-driven but rather emanate from polar-opposite ideologies.

A critique in The Economist assessed apparent political motivations underlying the presumed consensus among U.S. health care providers, including groups like the American Academy of Pediatrics, or AAP, that gender-affirming care is invariably beneficial and should be made as accessible as possible. But an empirical basis for relatively easy access is lacking. In 2020, the British National Institute for Health and Clinical Excellence published two systematic reviews — one on puberty blockers, the other on cross-sex hormones — which indicated no clear clinical benefit of such treatments regarding gender-dysphoria symptoms. The review found that analyses regarding the impact of puberty blockers were “either of questionable clinical value, or the studies themselves are not reliable.” On cross-sex hormones, the institute identified short-term benefits but said these “must be weighed against the largely unknown long-term safety profile of these treatments.”

Furthermore, based on a four-year review led by Hilary Cass, the National Health Service in England declared in March that puberty blockers will not be available to children and young people, unless they’re enrolled in clinical research trials. In April, the final report was released which reinforced the NHS policy change.

To take a more rational approach, the U.S. ought to adopt the European perspective and look to the forerunners in gender care — the Dutch. Caution is at the heart of the Dutch model of care for those presenting with gender dysphoria. Over a period spanning two decades, gender specialists in the Netherlands methodically compiled a comprehensive set of guidelines for providing trans care for minors, known as the Dutch protocol . The protocol outlines prerequisites  for care, which include documented onset of gender dysphoria during early childhood, an increase of the experience of gender incongruence after puberty, the absence of other significant psychiatric illnesses, and a demonstrated knowledge and understanding of the consequences of medical transition.

After a youth enters a clinic, they undergo a diagnostic phase that lasts at least six months, during which time there’s an intensive work-up involving detailed questionnaires and dialogue between the young person and a mental health support team. After that, youths who want to pursue a medical transition are prescribed puberty blockers, and it may be a couple more years before they become eligible for cross-sex hormones.

Treatment with puberty blockers typically begin around age 12. Irreversible and partially irreversible interventions, which include cross-sex hormones and surgery, cannot be given until the person reaches 16 and 18, respectively. Patients who go through with the transitioning process are provided with psychotherapy throughout.

To take a more rational approach, the U.S. ought to adopt the European perspective and look to the forerunners in gender care.

This watchful waiting approach to helping gender-diverse children is rejected by the AAP, psychologist James M. Cantor wrote in an analysis of the AAP’s policy. U.S. clinicians have criticized the Dutch process for being too slow and erecting unnecessary obstacles on the path of gender transition. They tend to favor quicker access to puberty blockers, cross-sex hormones, and even surgeries for young people. Although sex reassignment surgeries are relatively rare in the U.S., recent research using data from 2016 to 2020 show that 3,678 (7.7 percent) of them were in the 12 to 18 age group. In Europe, such surgeries for youth are mostly inaccessible .

And a growing number of European countries are  reevaluating  their approach to pharmaceutical care for gender-incongruent minors, indicating the need for even more caution than the Dutch Protocol provides. Medical experts point to the dearth of rigorous high-quality evidence to support the use of drugs. They base their assessments on a series of  systematic evidence reviews  conducted by public health authorities in Finland, Sweden, and England to determine the risks and benefits of puberty blockers and cross-sex hormones. The data collected and analyzed in the reviews suggest a risk-benefit ratio that is characterized as unknown , unfavorable, or insufficient on a scientific basis .

A landmark study published this year examined deaths from all causes and from suicide in Finnish adolescents and young adults who were seen at specialized gender identity clinics between 1996 and 2019. It found that pharmaceutical intervention or surgery was not linked to a reduction in suicide when researchers took psychiatric treatment history into account.

Study findings have informed changes in policy regarding treatment of gender incongruence in minors. Besides England, most health authorities are not instituting bans on treatment. However, currently in European countries that have traditionally been leaders in youth gender medicine — such as Sweden , Denmark , France and Finland , — patients under 18 typically only receive puberty blockers and cross-sex hormones if they meet strict eligibility requirements. Health authorities suggest that key questions remain unanswered, including the long-term effects of puberty blockers and hormones on bones, brain, sexual function, and fertility. In the meantime, clinicians are prioritizing approaches which seek to address possible psychological conditions that might accompany gender dysphoria and explore the psychological and other possible determinants of trans identity.

Despite these findings and the changing viewpoints in Europe, there’s intransigence on the part of AAP and other U.S. medical professional societies to alter course. Although after years of balking, AAP finally called for a review of the medical research, it continues to advocate for its position. In what amounts to a politically charged statement, the an editorial in the AAP journal Pediatrics stated that withholding gender-affirming care is “harmful to children and amounts to state-sanctioned medical neglect and emotional abuse.”

Europe’s approach of not banning but instead restricting medicalized transgender care for minors stands in stark contrast to the U.S. Changes in policies are dictated by emerging clinical evidence, not gender-identity politics or theological ideology.

Joshua Cohen is an independent healthcare analyst and freelance writer based in Boston.

This article was originally published on Undark . Read the original article .

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Joshua Cohen is a writer who lives in Pennsylvania.

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