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Surgical Options

This section provides background information on the surgical procedures patients may be considering, or may have already undergone.

Primary care physicians may recommend procedures necessary for a patient's over-all health and well-being, such as a hysterectomy/oophorectomy for a female-to-male patient, or urological consults for a male-to female patient, and to assist patients in understanding surgical options. Primary care physicians need to know how these procedures may impact or be impacted by transsexual surgeries.

Primary care physicians may provide post-operative care for patients who have had surgery in another state or country.

Primary care physicians also may be called upon to advocate with insurance carriers or with other specialists for a patient's medical needs.

Male-to-Female Surgeries

Orchiectomy

Orchiectomy--this is the removal of the testes. Some transwomen will have this procedure without a vaginoplasty or penectomy. Estrogen therapy in progress may need to be adjusted post-orchiectomy; orchiectomy may permit lower doses of estrogen therapy and eliminates the need for testosterone blockers.

Vaginoplasty

Vaginoplasty--this is the construction of a vagina to enable female sexual function using penile tissue or a colon graft. The procedure usually involves clitoro-labioplasty to create an erogenously sensitive clitoris and labia minora and majora from surrounding tissues and/or skin grafts, as well as a clitoral hood. Colon grafts do not require dilation and are self-lubricating; however the lubrication is present at all times and may become bothersome. Additionally, colon grafts must be screened for colon cancer and should be monitored if the patient develops inflammatory bowel disease. (See images.)

Penectomy

Penectomy--this is the removal of the penis. This procedure is not commonly done. Generally, penis removal is done in concert with vaginoplasty. In some surgical techniques, the penile skin is used to form the vagina, so this is not a straightforward amputation, but a potentially complex procedure intended to utilize analogous tissue as well as maintain nerve function to preserve sexual responsiveness.

Breast Augmentation

Breast Augmentation--if breast growth stimulated by estrogen is insufficient (only progressing to the 'young adolescent' stage of breast development), augmentation mammoplasty may be medically necessary to ensure that the patient is able to function socially as a woman.

Reduction Thyroidchrondroplasty

Reduction Thyroidchrondroplasty--this procedure reduces prominent thyroid cartilage.

Voice Surgery

Voice Surgery--this still-evolving procedure is intended to raise the pitch of the speaking voice. Speech therapy is recommended prior to seeking a surgical solution.

Facial Feminization

Facial Feminization--includes a variety of aesthetic plastic surgery procedures that modify the proportions of the face to facilitate social functioning. These procedures are medically necessary.

Female-to-Male Surgeries

Chest reconstruction / bilateral mastectomy

Chest reconstruction / bilateral mastectomy--this is the procedure most frequently required by transmen. A variety of techniques may be used, depending on the amount of the patient's breast tissue. Scarring may result, and nipples may be large or small and grafted, depending on the surgeon's technique. (See image.)

Hysterectomy/oophorectomy

Hysterectomy/oophorectomy--this procedure may be necessary in the event of fibroid growth, endometrial conditions, or as a prophylactic procedure in patients with a family history of cancer. Hysterectomy may be a part of a phalloplasty/vaginectomy procedure when the vaginal tissue is used to construct the urethral canal.

Metoidioplasty

Metoidioplasty--the construction of male-appearing genitalia employing the testosterone-enlarged clitoris as the erectile phallus. The phallus generally will be small and has the appearance of an adolescent penis, but erectile tissue and sensation are preserved. This procedure releases the clitoral hood, sometimes releasing the suspension ligaments to increase organ length, may involve raising the position of the organ a centimeter or so toward the anterior, and may include scrotoplasty and (less frequently) urethroplasty. Closure of the vaginal opening may be full or partial, or the vaginal opening may not be impacted at all, depending on the surgeon's technique. This procedure is much less invasive than a phalloplasty procedure, and emphasizes preservation of erotic sensation. (See images.)

Phalloplasty

Phalloplasty--the construction of a phallus that more closely approximates the size of an erect male organ, using tissue from another part of the patient's body. Size and appearance are prioritized over erectile capacity, and in some cases over erotic sensation. Skin flaps used in this procedure include abdominal flap (no erotic sensation), radial forearm flap, deltoid flap, and calf flap (all of which contain nerves that may be grafted to the pudendal nerve to provide erotic sensation). Erectile capacity is provided via implanted semi-rigid or inflatable penile prostheses. (See images.)

Scrotoplasty

Scrotoplasty--the construction of a scrotum, usually using labia majora tissue and saline or silicone testicular implants. Some surgeons will use tissue expanders and place the implants after the tissue has been stretched sufficiently to accommodate the implants. This procedure is rarely done separately, but is usually performed in conjunction with either a metoidioplasty or a phalloplasty procedure, and with some phalloplasty/urethral extension techniques it may be necessary to perform the scrotoplasty as a later stage, after urethral healing.

Urethroplasty

Urethroplasty--the creation of the urethral canal through the neophallus to facilitate standing micturation. This is usually, but not always, done in conjunction with genital reconstruction. Some transmen will avoid this procedure due to the potential for complications, or their genital plastic surgeon may not be willing or able to perform this procedure, either as a matter of general practice, or specific to the patient's body habitus.

Vaginectomy

Vaginectomy--the removal of the vagina may be done with ablative technique or surgical techniques. This is required if the vaginal opening is going to be closed.