A Short Guide to Surgical Interventions for Masculinising Trans and AFAB Non-Binary Individuals
[Trigger Warning: Mentions genitalia and surgical procedures]
This post will provide a brief overview of the most common forms of surgery available to help masculinise transgender and AFAB non-binary individuals.
Chest reconstruction is a procedure that removes the female breasts in transmen and AFAB non-binary individuals to create a natural-looking male chest.
While the double incision technique is the most common method of breast removal, the buttonhole technique and inverted T technique are also available though this depends on the size of the breast and restrictions on the position of the nipple. Ultimately, the availability of choice ultimately depends on the individual surgeon and what techniques they are able and willing to carry out.
Types of Chest Reconstruction:
Bilateral Mastectomy (Double Incision): This is the most common surgical method for removing breasts in trans people. Incisions are made at the crease of each breast or slightly under and the nipple-areolar complex is removed as a skin graft so it can be resized and repositioned to give a masculine appearance.
Periareolar Surgery: This form of top surgery is only effective when the patient’s breast is already very small. This method involves minimal movement of the nipple. An incision is made around the areolae and the tissue inside is removed via the incision. This technique leaves minimal scarring.
Inverted T: The Inverted-T procedure is similar to Double Incision except that the nipple is not removed and grafted back onto the chest.
[If you would like to read about my personal experience of having Top Surgery, you can find the post here: https://transistus.tumblr.com/post/622730616100782080/i-had-top-surgery-double-incision-with-mr-miles]
Salpingo-Oophorectomy is the removal of the fallopian tubes and ovaries and a hysterectomy is the removal of the uterus.
A salpingo-oophorectomy results in permanent destruction of the ovaries and is irreversible. After oophorectomy you will be infertile and unable to have children unless you have previously carried out gamete storage.
After salpingo-oophorectomy, you will need to take at least one sex hormone in order to prevent medical problems like osteoporosis
A hysterectomy is the removal of the uterus. A hysterectomy may be laparoscopic, vaginal, or abdominal. A total hysterectomy is where the uterus is removed via the vagina. Different types of hysterectomies are available though the most common is a radical hysterectomy as this method removes the uterus, cervix, ovaries and Fallopian tubes.
Hysterectomy results in permanent destruction of the uterus and is irreversible. After having a hysterectomy you will be unable to become pregnant or give birth.
Not all types of hysterectomy remove the risk of cervical cancer. The cervix is only removed as part of an operation called a “total hysterectomy”.
Genital Surgery: Metoidioplasty
Out of the two genital surgeries available to transmen and AFAB non-binary individuals is metoidioplasty (also known as ‘meta’).
Meta is significantly less of a major surgery compared to phalloplasty. Meta is only possible following the use of testosterone as it relies on the growth of the clitoris.
Metoidioplasty in the UK is performed in at least two operations which take place several months apart. The number of operations and time between them will depend on whether the ability to stand to urinate or testicular implants are required.
In a metoidioplasty, the clitoris is detached from the labia and the ligaments which hold the clitoris are cut which adds 2-4cm in length to the clitoris and allows it to point upwards.
Urethroplasty can also be performed to allow urinating from the end of the clitoris. A urethroplasty is optional, you can continue urinating from your existing urethral opening if you want, though this would require continuing to sit to urinate or using a stand to pee device. Not having a urethroplasty reduces the risk of complications.
In combination with metoidioplasty, you can optionally also have testicular implants added.
It is important to remember that clitoral growth from testosterone is limited to a maximum size of 2-3 inches and therefore is unlikely to allow the patient to use it for penetrative sex. However, sexual sensitivity is often well-preserved.
Bladder or rectal injury.
Prolonged need for drainage.
Dissatisfaction with the size or shape of the penis.
Inability to stand-to-pee.
Genital Surgery: Phalloplasty
Phalloplasty is surgery to create a penis, usually with the ability to urinate out of the end of it, and to make it erect. It usually takes several separate surgeries to complete, with healing time in between them, and may take more than a year to complete.
There are three surgical techniques used to form the phallus which differ in which site skin is taken from:
Radial Artery Phalloplasty: This is the most commonly used technique and is the procedure of choice if standing to urinate, cosmetics and sensation are the prime requirements. The penis is formed using skin from the forearm which usually has 3 nerves that come with it and is therefore more likely to develop sensation than any other kind of phalloplasty. Nerves do grow slowly and it can take a couple of years for sensation to appear. Surgeons will harvest skin from the buttock to create a full thickness grafts for the forearm though scarring is noticeable.
Abdominal Phalloplasty: A rectangular shaped skin flap is raised from the lower abdominal skin. Abdominal phalloplasty tends to have less sensation than the radial artery phalloplasties. They have no feeling towards the tip because all the nerves get cut during the flap elevation. This surgery may not be possible if you have had surgeries on your abdomen such as Caesarian section or hysterectomy.
Antero-Lateral Thigh Phalloplasty: This type of phalloplasty is made from the skin and fat on the front and side of the thigh. Very few patients are suitable for this method as it requires that the subcutaneous fat on the thigh be not too thick. There is however only a single nerve with this flap so even with a nerve hook-up, sensation is not as good as with the forearm flap method. The large donor site defect is covered with a split skin graft from the other thigh.
The amount of sensation in the penis will depend on the technique used, with radial artery phalloplasty giving the best results. There is no guarantee of sensation.
Phalloplasty is often split into manageable stages so that the operations are not too complicated and patients’ bodies can get a rest in between each stage, which is important.
STAGE 1: Formation of the phallus and/or neo-urethra in phallus.
STAGE 2: Glans sculpting, scrotoplasty and connect neo-urethra to bladder.
STAGE 3: Erectile and testicular prosthesis.
If a patient wants a neo-urethra then this has to be completed before the penile prosthesis is implanted. If there is an unsatisfactory result or complication from any stage then this is normally corrected before moving on to the next stage.
Several options are available for people who wish to have erections:
Inflatable Prostheses: This is an implant inside the penis that is usually inflated by a pump, usually hidden inside one of the testicular prostheses, which you squeeze to inflate the penis implant.
Malleable Rods: These are implanted into the penis. Be aware that these are not usually used in the UK as the implant exerts constant pressure on the skin, causing damage over time.
External Aids: These are devices worn around the penis to either provide support to hold it straight and stiff.
Potential Complications (phallus):
Bladder or rectal injury.
Erosion (erectile devise protrudes through the skin).
Potential Complications (graft):
Unsightly scarring or discolouration.
Decreased mobility (rare)
Despite advances in surgical techniques there is no perfect technique and as I have mentioned above, each approach has its own drawbacks. Patients will need to consider the following factors when deciding which approach is most appropriate to their needs:
Removal of external and internal female parts
[If you would like to read about my personal experience of having Radial Artery Phalloplasty, you can find the post here: https://transistus.tumblr.com/post/623459065893355520/stage-one-phalloplasty-experience-and-results]
