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Surgical Options for Trans Masculine (FTM) Individuals

 

In transgender men, or transmasculine people (FTM), the surgical procedures for transtition include top surgery (bilateral mastectomy with chest reconstruction), hysterectomy and/or oophorectomy, metoidoplasty, scrotoplasty, uretheroplasty, vaginectomy, and phalloplasty.

Top Surgery (bilateral mastectomy with chest reconstruction) is by far the most frequently required surgery for transmasculine individuals.  A variety of techniques can be used including peri-areolar, keyhole, or double incision technique. Scarring and decreased nipple sensation may result. Testosterone is not a requirement to undergo top surgery. Check out the different techniques via informingconsent.org: Peri-Areolar and Double Incision.

Hysterectomy/Oophorectomy is also fairly common for people who have dysphoria from the presence of reproductive organs, and/or other painful gynecological issues that exacerbate dysphoria. They do have the option of keeping one or both ovaries--if testosterone is not being used or will potentially not be used in the future, keeping one or both ovary  may  be advantageous so that the body has some hormones available to regulate other important biological processes like maintaining bone density. Hysterectomy is usually required prior to undergoing vaginectomy, scrotoplasty, and phalloplasty.

Metoidioplasty (clitoral release) is the severing of the suspensory ligament of the testosterone-enlarged clitoris, and the separation of the clitoris from the labia minora so the clitoris hangs fully forward (~2 inches).  The labia minora is then wrapped around the clitoris and sewn along the midline to create a convincing penis.  Erectile abilities and sensation are preserved, and mild penetration can be achieved. This procedure may also include urethroplasty, so urination through the clitoris may be achieved, and/or any combination of vaginectomy and scrotoplasty. This procedure is much less invasive and expensive than a phalloplasty procedure and emphasizes preservation of erotic sensation. Fistula is always a risk with urethroplasty.

Scrotoplasty is the construction of a scrotum, usually using labia majora tissue and silicone testicular implants. This procedure is usually performed in conjunction with either a metoidioplasty or phalloplasty procedure.

Urethroplasty is the creation of the urethral canal through the neophallus to facilitate standing urination. This is usually, but not always, done in conjunction with metoidioplasty or phalloplasty.

Vaginectomy is the removal of the vaginal tissue. This may be done with ablative or surgical techniques. It is required to close the vaginal opening.

Phalloplasty is the construction of a phallus that more closely approximates the size of an erect male-assigned penis, using a graft from another part of the patient's body (usually forearm or thigh). Size and appearance are prioritized over erectile capacity, and in some cases over erotic sensation. Urethroplasty usually is done simultaneously so standing urination abilities are achieved.  Erectile capacity is achieved via penile implant (which occurs in a second surgery) of a semi-rigid or inflatable penile prostheses.  Fistula is always a risk with urethroplasty. Click to here to see Informing Consent's video of Dr. Crane discussing how the nerve connection works!

 

Not all transgender patients will want to have surgery as a part of gender transition, and for many it is not possible due to insurance or financial barriers.  The risks, benefits and alternatives should be discussed with each individual along with their personal goals for transition to determine the right course.

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