Trans Masculine Surgeries

Introduction

Time to Read 20 mins

This section will be covering most of the common surgeries trans-masculine or non-binary people would consider. Not every surgery will be covered, as some are extremely specific, the information provided on this website is intended to be relevant for everyone. Additionally, links and information will be provided for Ontario residents on how to access these surgeries and funding.

Bilateral mastectomy vs Top surgery

Top surgery removes breast tissue and liposuctions the remaining tissue into a shape typically considered more masculine (Rainbow Health Ontario, 2024 p. 8). There are multiple techniques that can be used and the decision is made between patient and surgeon, often, the surgeon recommends a specific technique based on cup size, skin elasticity, nipple and areola size/position and the patient’s goals (Rainbow Health Ontario, 2024 p. 8). Top surgery is covered by OHIP for patients with a letter of recommendation written by their doctor (Rainbow Health Ontario, 2024 p. 11).

Keyhole Mastectomy

Keyhole mastectomies are recommended to patients with an A cup; it involves a half-moon incision made along the bottom of the areola. Breast tissue is removed via liposuction and removal through the half-moon incision. Because the nipple and areola are not fully removed, sensation is often possible post-operation. (Rainbow Health Ontario, 2024 p. 9).

Periareolar Mastectomy

Periareolar mastectomies are recommended for people with a B cup or less and good-moderate skin elasticity. This technique involves making an incision around the entire areola but not removing it so sensation is still possible. Breast tissue is removed via liposuction and excision, sometimes the areola can be re-shaped to better align with a masculine nipple/areola. The skin is then pulled tight around the areola before being re-attached and the surgeon may reposition the areola to align with patient goals (Rainbow Health Ontario, 2024 p. 9).

Double Incision Mastectomy

Double incision mastectomies are recommended for C-cup or larger and/or excess skin. This technique involves horizontal incisions across the chest, the surgeon then removes excess tissue and excess skin, sometimes fatty tissue is liposuctioned. Incisions are closed leaving horizontal scars under the pectoral muscle lines. This technique does not directly effect the nipple and areola so surgeons can additionally perform a “free nipple graft” completely removing the areola and nipple, reshaping them and re-attaching them. Sensation can be lost as many nerves are severed in this process (Rainbow Health Ontario, 2024 p. 9).

Inverted T Mastectomy

Inverted T mastectomies are similar to a double incision but with an extra vertical incision. The difference is the areola and nipple are left partially attached, the downside is total flatness of the chest cannot be achieved via this method, additionally, some surgeons do not perform this technique (Rainbow Health Ontario, 2024 p. 9).

Risks to any form of top surgery

Risks to any form of top surgery include the following to varying degrees depending on the method chosen.

  1. All techniques are irreversible
  2. All come with a change in sensation and risk of numbness from nerve damage
  3. There is a possibility of hypersensitivity due to severed nerve endings
  4. Incision sites have a chance of separating leading to more prominent scarring
  5. Permanent scarring is always a potential with large incisions
  6. Partial or full nipple graft failure, meaning after the nipple is re-attached the body can reject it. There is potential for a second surgery to reconstruct a new nipple or have it tattooed on
  7. Changes in colour of nipple and areola
  8. Asymmetry
  9. Uneven skin i.e. excess skin, bulges, puckering
  10. Hematoma/Seroma where blood and fluid collect under the skin causing redness, bumps and pain. These may need to be drained by a doctor

Post operative care

Post-operation care involves drains for excess fluid that are removed roughly 1 week after surgery but can take longer (Rainbow Health Ontario, 2024 p. 12). Most surgeons use dissolvable stitches that will dissolve after 4-6 weeks. Dressings and steri-strips are left on for a week and patients cannot shower during this time. Finally, some surgeons recommend wearing a compression band for 1-month post-op (Rainbow Health Ontario, 2024 p. 12).

Other considerations include:

  1. A minimum of 1 week off work
  2. No exercise of lifting objects over 10 pounds for a week
  3. No driving for at least 1 week

Long term recovery looks like:

  1. Swelling for 4-6 months post-op, full recovery takes 12-18 months
  2. No direct sunlight on scars to promote healing
  3. Potential of some left over breast tissue, so a follow up may be needed

 

Phalloplasty

Phalloplasty is the creation of a phallus or penis using tissue such as skin, fat, nerves, veins and arteries from elsewhere on the body and attaching it to the pubic area (Rainbow Health Ontario, 2024 p. 33). Phalloplasty on its own does not equate a working penis, multiple techniques are used to achieve a neo-penis.

In addition to phalloplasty one might consider:

  1. Total hysterectomy
  2. Vaginectomy: removal of vagina and closing of vaginal canal
  3. Urethral lengthening: which is required if you want the urethra to travel through the phallus
  4. Burying the clitoris in the base of the phallus
  5. Glansplasty: creation of the glans penis by sculpting head of phallus
  6. Monsplasty: removal of prominent prepubic tissue
  7. Scrotoplasty/perineal reconstruction: creation of a scrotum
  8. Testicular implants
  9. Erectile device: insertion of a device into the phallus for erectile function

Tissue options for shaft construction

As there are many different surgeries that cumulatively make a neo-penis, there are options for which tissues are used depending on what the patient wants, for construction of the shaft, options are (Rainbow Health Ontario, 2024 p. 34).

  1. Shaft only, leaving the urethra in its original position. This means a patient cannot pee standing up, vaginectomy and scrotoplasty are possible for this.
  2. Shaft with urethra: One piece of tissue forms two tubes, or a ‘tube within a tube’. One has skin on the outside for the shaft of the phallus and one has skin on the inside for the urethra.

Donor sites

There are 2 donor sites mainly used for this surgery, they are chosen because of their reliable blood supply which increases the chance for sensation, they are (Rainbow Health Ontario, 2024 p. 34).

  1. Radial forearm free flap: Skin, blood vessels and nerves from the forearm are used to make the phallus.
  2. Anterior lateral thigh flap: Skin, blood vessels and nerves from the side of the thigh are used to make the phallus. When possible, the blood supply is left attached (pedicled flap) and only the nerves are cut and reconnected.

These are the most common donor sites, however, some surgeons may consider using the abdominal flap for shaft only phalloplasty. The downside is this technique doesn’t involve nerve connections so sensation will be limited. The other is tissue from the torso under the armpit, essentially the top of the ribcage before your armpit (Rainbow Health Ontario, 2024 p. 34).

Surgical steps

Phalloplasty is done in multiple steps, these are:

  1. Hysterectomy (removal of uterus) and hair removal
  2. Phallus creation with the option of urethral lengthening
  3. Erectile and testicular implants

Keep in mind this is a rough step by step template; there may be more than 3 surgeries involved especially if complications arise. The process takes 2-3 years on average (Rainbow Health Ontario, 2024 p. 35).

Steps must be completed in order, permanent hair removal can take up to a year and must be finished before step 2. Step 2 involves the creation of the phallus from whichever tissue was chosen, a skin graft (artificial skin) will be used to cover the donor site (Rainbow Health Ontario, 2024 p. 35). Surgeons perform a microsurgery for all the tiny things, like blood vessels and nerves from the neophallus to current genitals. If undergoing urethral lengthening, a urethra is created within the phallus in a ‘tube within a tube’ approach. Additionally, vaginectomy, glansplasty, scrotoplasty, perineum reconstruction and burying of the clitoris may take place. If undergoing phalloplasty with urethral lengthening (where urethra is extended to the end of the phallus), vaginectomy is usually required due to the increased risk for urethral vaginal fistula (requiring additional surgical procedures with uncertain results). If undergoing phalloplasty without urethral lengthening, vaginectomy is not a requirement (Rainbow Health Ontario, 2024 p. 35).

Urethral lengthening approaches 

If the urethra is being lengthened, often step 2 is split into 2 different surgeries. For surgery, the urethra is listed as 3 separate parts, the native urethra (already attached to your body), the penile urethra which goes through the shaft, and the fixed urethra which connects the 2.

Single stage approach involves everything being done at once, you can pee standing up immediately after recovery.

A two-stage approach can also be done in 3 different ways:

  1. Everything is done at once, but the penile urethra and fixed urethra are not connected until after recovery. (it does not say why, I am guessing to help avoid infection as things heal)
  2. The first surgery will only be to create the phallus and penile urethra. A second surgery will include vaginectomy, glansplasty, scrotoplasty, perineum reconstruction, burying of the clitoris and the urethra is connected.
  3. The first surgery is a metoidioplasty (info down below) and includes, vaginectomy, scrotoplasty, perineum reconstruction and urethral lengthening. The second surgery creates the phallus with the penile urethra and connecting it to the urethra which was elongated during the first surgery or metoidioplasty. Finally, the clitoris is buried at the base of the phallus.
  4.  Finally, the third step includes inserting testicular implants into the scrotum and erectile implants in the phallus that will allow for insertive sex. There are different types of implants including ridged, malleable and inflatable (Rainbow Health Ontario, 2024 p. 35).

Surgical Risks

Urethral complications are very common if you decide to get an elongated urethra, one should be prepared for surgical revision (Rainbow Health Ontario, 2024 p. 36). Risks include:

  1. Urethral fistulas: results in an unwanted leak between the urethra and the skin or vagina
  2. Urethra strictures: a narrowing of the urethra at any point within the phallus making it difficult or impossible to pee
  3. Blader spasms: which may result in the need for a catheter (bag you pee into via a tube up your urethra)
  4. Urethral diverticula: a pocket or pouch that forms along the urethra and can cause urine to pool leading to incontinence
  5. Lower urinary tract symptoms: basically, issues with pee like dribble, spraying, poor flow, incomplete emptying
  6. Hair growth in urethra: which can cause UTI’s, stenosis, stricture, intra-urethral stones

Other complications include:

  1. Large permanent scar, numbness, stiffness, swelling, weakness, decreased flexibility, pain and general morbidity to the donor site, possibly extending to other parts of the limb (i.e. hand)
  2. Scarring to donor site, genital region etc. scarring will vary greatly based on technique
  3. The skin graft being rejected or dying
  4. Flap loss/graft failure: all or part of your phallus dies normally due to poor blood loss
  5. Nerve damage
  6. Decreased sexual satisfaction
  7. Dissatisfaction with appearance
  8. Injury to bladder or rectum
  9. Wound breakdown: delayed healing, hyper granulation and other complications of skin healing
  10. Testicular implant complications
  11. Erectile device complications
  12. Perineal pit: the area between anus and phallus can form a small pit and have hygiene issues
  13. Vaginal remnant or mucocele: vaginal tissue may be left behind after vaginectomy and a collection of fluid and cells in your pelvis may result. If it is connected to the urethra, it may cause substantial post-void dribbling/incontinence. This may require surgical revision to remove the tissue.
  14. Negative mental health impacts of surgery

Managing complications

As stated before, phalloplasty is complex and involves multiple surgeries. Complications resulting in additional surgeries are fairly common (Rainbow Health Ontario, 2024 p. 37). One of the most common issues that happens during recovery are strictures. Strictures is the abnormal narrowing on a body part such as a urethra or intestine. As a result, you may need to:

  1. Insert a catheter from your lower abdomen into your bladder
  2. Insert a catheter from urethra to bladder
  3. Cut out a short segment of the urethra and close it directly
  4. Urethral dilations

If the stricture is long additional surgery may be required. This surgery is done in 2 parts, part 1 is using tissue from the inside of your mouth to create a new section of urethra. Part 2 involves using a tiny catheter to support and drain the bladder until everything heals and urinating out of the phallus is once again possible (Rainbow Health Ontario, 2024 p. 37). Other complications involve fistulas which is when 2 parts of the body aren’t supposed to connect but do, this may require a minor surgery to fix and implant infections which usually results in removal of the implant and replacement once everything has healed (Rainbow Health Ontario, 2024 p. 37).

Recovery

Generally speaking patients will spend 5-7 days in the hospital the operation is performed in followed by another 5-7 days in a nearby outpatient centre (Rainbow Health Ontario, 2024 p. 39). The surgeon may ask patients to spend another 3-6 weeks in close proximaty if complications arise.

Metoidioplasty

The goal of Metoidioplasty is to create a small phallus with full sensation. There are many additional surgical techniques that can be done alongside metoidioplasty. If the priority of creating a phallus is for incentive sex, phalloplasty surgery should be considered instead (Rainbow Health Ontario, 2024 p. 43).

Please read the above phalloplasty section beforehand as many of the techniques and descriptions will be based on phalloplasty or presume the patient has a rough idea of phalloplasty in mind. Similarly to phalloplasty, metoidioplasty can be done with or without urethral lengthening allowing the patient to pee standing up. Unlike phalloplasty however, metoidioplasty can be done as a single surgery (Rainbow Health Ontario, 2024 p. 43).

Options for metoidioplasty

Options for metoidioplasty are as follows, surgical techniques very by surgeon and by patient goals:

  1. Vaginectomy — removal of the vagina and closure of vagina. This may be required if the patient wants urethral lengthening and scrotoplasty (creation of scrotum)
  2. Clitoral enlargement — surgical release clitoris from attachments around it such as ligaments
  3. Monsplasty — reducing fatty tissue around the pubic bone, this will improve the prominence of a phallus and is not recommended if patient will consider phalloplasty in the future.
  4. Urethral lengthening — construction of a new urethra to add on to current one, this will allow patient to pee standing up.
  5. Scrotoplasty — creation of a scrotum using outer labia, labia tissue may also be used to add girth to the phallus.
  6. Testicular implants — can be inserted.

References

Vincent, B. (2018). Transgender health: a practitioner’s guide to binary and non-binary trans patient care. Jessica Kingsley Publishers.

Ontario Ministry of Health. (2023). Gender confirming surgery. Ontario.ca.

Public Health Agency of Canada. (2024). How to access gender-affirming care: Options. Canada.ca.

Rainbow Health Ontario. (2024). Gender affirming surgery: Summary sheets, series 1 [PDF].

 

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