Masculinizing surgery

Many people seek masculinizing 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 masculinizing 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.

Options for masculinizing surgery include:

• Surgical removal of breast tissue. This also is referred to as top surgery or masculinizing chest surgery.
• Surgical placement of pectoral implants to create a male-contoured chest.
• Genital surgery to remove the uterus and cervix — a total hysterectomy — or to remove the fallopian tubes and ovaries — a procedure called salpingo-oophorectomy.
• Surgery to remove all or part of the vagina, called a vaginectomy, create a scrotum, called scrotoplasty, place testicular prostheses, increase the length of the clitoris, called metoidioplasty, or create a penis, called phalloplasty.
• Other procedures such liposuction, a technique to remove fat from specific areas of the body, and fat grafting.

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 major surgery, many types of masculinizing 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 nipple or in the surgically created penis
• A blood clot in a deep vein, called deep vein thrombosis, or a blood clot in the lung, a condition called pulmonary embolism
• Development of an irregular connection between two body parts, called a fistula, such as in the urinary tract
• Urinary problems, such as incontinence
• Pelvic floor problems
• Permanent scarring
• Loss of sexual pleasure or function
• Worsening of a behavioral health concern

Fertility

Certain types of masculinizing 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 about your options. You may choose to freeze eggs with a procedure called mature oocyte cryopreservation, or freeze embryos using embryo cryopreservation. Another option involves having ovarian tissue surgically removed, frozen, and later thawed and reimplanted. That procedure is called ovarian tissue cryopreservation.

Egg freezing involves multiple steps, including ovulation induction, egg retrieval and freezing. If you want to freeze embryos, an additional step of having the eggs fertilized before they are frozen also is required.

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.

Consent

Because masculinizing surgery might cause physical changes that cannot be reversed, you must give informed consent after thoroughly discussing:

• Risks and benefits
• Cost
• 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
• Lab tests
• 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 masculinizing 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 masculinizing 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.

Chest surgery

Top surgery, also called masculinizing chest surgery, involves the removal of breast tissue — a procedure known as subcutaneous mastectomy. There are several approaches for this surgery, including:

• Double incision mastectomy. This procedure may be recommended for people with larger breasts. During surgery, the surgeon makes cuts under and on top of each breast. Breast tissue and some chest skin is removed. The shape and location of the nipples may need to be changed. To do this, the surgeon removes the nipples and makes them smaller and more oval shaped. Then they are reattached to the chest wall. After this surgery, there is no feeling in the nipples and areolas.
• Subcutaneous mastectomy with nipple preservation. If your breasts are smaller, this approach may be an option. The surgeon makes cuts under the breasts and removes breast tissue. Usually no skin is removed. The nipples may be reshaped, but the nipples and areolas stay attached. This helps preserve feeling in the nipples.
• Periareolar mastectomy. This surgery may be used if your breasts are not large. A small cut is made around the areola of each breast and the breast tissue is removed. Usually, no skin is removed. The nipples and areolas stay attached. This helps preserve feeling in the nipples.

After surgery, you may need to stay in the hospital overnight. You might not be able to bear weight on your upper body for six weeks. Talk to your health care provider about the specific activity restrictions you need to follow.

Some breast tissue remains after surgery regardless of the surgery you have. Because of that, ask your health care provider about breast cancer screening you may need after surgery.

Genital surgery

Metoidioplasty

Metoidioplasty is a procedure to increase the length of the clitoris without adding other tissue. During surgery, the clitoris is freed from its attachment against the body. The surgeon also can extend the urethra through the released clitoris using a graft typically taken from the lining of the mouth. This is called a urethral hookup. It makes standing urination possible.

This procedure usually results in a penis with an unstimulated length between 1 and 3 inches (3 and 8 centimeters). Typically after this surgery, you still have full sensation and the ability to have an orgasm.

It isn't necessary for the vagina to be closed or removed before metoidioplasty. But penetration and Pap tests might not be possible after it. As a result, your surgeon might suggest removing your uterus, cervix and ovaries during metoidioplasty.

After metoidioplasty, you have a tube temporarily placed in your urethra to collect urine. Recovery might take up to two weeks.

Phalloplasty

Phalloplasty, the surgical creation of a penis, involves several procedures. During phalloplasty, large amounts of skin are taken from other areas of the body. These may include the forearm, calf or lower abdomen. This can cause significant scarring. The skin is rolled into the shape of a penis and anchored into position above the clitoris. Phalloplasty also may include:

• Urethral lengthening to allow for urination through the penis
• Grafting of nerves and blood vessels to provide sensation
• Sculpting the head of the penis — a procedure called glansplasty
• Medical tattooing to create a distinct difference between the head and shaft

After phalloplasty, a tube is temporarily placed in the urethra to collect urine. You'll likely need to stay in the hospital for a few days. Phalloplasty carries a high rate of complications. It could require many follow-up surgeries. Depending on the procedure, recovery might take up to 12 weeks. The new penis will not become erect with sexual stimulation. A penile implant is needed to allow penetrative sex.

Scrotoplasty

Scrotoplasty is the surgical creation of a scrotum. During scrotoplasty, testicular implants are inserted into the labia. To prepare for the procedure, expanders are placed under the skin. The expanders are gradually filled with saline over several months. When the skin has been expanded enough, the implants are inserted. Some people find the implants uncomfortable. It is possible for the implants to wear through surrounding tissue or become infected.

Other masculinizing surgeries also are available, including surgery to place pectoral implants in the chest, as well as procedures to remove fat and fat grafting. Ask your health care provider about these options and the risks and benefits they involve.

Research has found that 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.