Male chest reconstruction is one of the top surgeries for female-to-male sex reassignment. The procedures involve masculinization of the chest by removing the breast tissue and resizing or reshaping the areola and nipples. This method removes the subcutaneous tissue from the inside of the breast along with excess skin.

Surgery Options

1. Double incision
2. Inverted-T
3. Keyhole

Before the surgery

• Obtain clearance from your therapist for a chest surgery
• Prepare a pre-op evaluation
• Maintain a healthy diet at least two weeks prior to the surgery
• Quit smoking two to six weeks before and after the operation
• Plan for post-op appointments

Chest reconstruction procedure

Double Incision: This is one of the most common male reconstruction surgeries. It involves incisions above and below the breast to remove the fatty tissue. Scars are inevitable beneath the pectoral muscles. Free nipple grafting is usually combined with this method, where the nipple and areola are removed, resized, reshaped and restored to the chest. The areolas are downsized as female areolas appear larger than male areolas. In the case of your body rejecting nipple grafting, your surgeon will tattoo your nipple back cosmetically or may use further surgical attempts. The procedure severs the nerves on the nipples, but you can hope for some sensation to return.

Inverted-T: This approach is called a transverse inframammary incision, and it includes free nipple areola grafting. Here, the areola is trimmed depending on what you have decided with your surgeon. Your nipple will have a pie-shaped excision which will be reconstituted.

Keyhole: Patients with small breast size choose keyhole incision. A small incision is made in the lower part of the areola to remove the underlying glandular tissue. Removing excessive skin is not necessarily done in this method.

After the surgery

• Until your first post-op appointment with your surgeon, your chest will be covered with surgical garments.
• There will be two drains from your dressing to prevent fluid from accumulating in your chest.
• You will experience itching and pain as your incisions heal, which is normal.
• Showering should be avoided before your first postoperative appointment. You will be directed to keep your dressing dry for two weeks.
• Expect soreness for at least a week after the surgery.
• There will be restrictions on strenuous activities and heavy exercise for two weeks after the surgery.

Risks and Complications

The common risks accompanying a male chest reconstruction surgery are infections on the incision site, blood loss, blood clotting and loss of nipple sensation. The risk of excessive blood loss commonly occurs in double incision approach as it requires cutting a longer length of the skin compared to other methods.

Post-Op Care

• Smoking and alcohol intake should be totally avoided before and after the surgery.
• You can expect to resume normal work after a week or two
• Keep the incision region dry for at least a week
• Maintain a healthy diet
• Avoid lifting heavy weights
• Itching and pain in the incision area are normal after surgery. If the pain continues or gets worse, consult your doctor without delay.

FAQs

If I have big breasts can I still get a masculine flat chest?

A: Yes, your surgeon will choose the type of surgery you will undergo depending on the size of your breasts. For large breasts, the double incision method is suitable.

How dangerous is top surgery?

A: The risks will include excessive blood loss, blood clotting, loss of nipple sensation, anesthesia risks, and hematoma. But the dangers accompanying this surgery will also depend on your medical history, so a thorough discussion with your surgeon will be wise.

Will my breasts grow back after chest reconstruction surgery?

A: Surgeons usually leave some fat for a natural male chest after the surgery. If you have stopped taking testosterone medications or have not removed your ovaries, the feminine pattern would still run as you gain weight. In this case, there is a chance for your breasts to grow back. You can avoid this by following a healthy diet and exercise regime following the surgery.

What is the level of pain after the surgery?

A: If you follow the instructions for postoperative care, you will not be facing extreme pain. Any pain or discomfort will be managed by the prescribed medications from your surgeon.

References:

https://www.healthline.com/health/transgender/top-surgery

https://www.genderconfirmation.com/ftm-chest/

https://www.hey.nhs.uk/patient-leaflet/gender-reassignment-surgery-female-male-breast-surgery/

Richard Troy

Medical Blogger committed to accuracy, I am passionate about delivering my readers critical insights into the medical field.
Former paramedic, instructor and medical school student.
You can read more about me in the dedicated section of the website.

www.medtravel.asia/about-richard-troy-medical-blogger/

The post Female to Male Top Surgery: Chest Reconstruction appeared first on MedTravel Asia.

Body masculinization involves a series of surgeries that transforms your feminine curves into a masculine physique. Though surgery alone may not give you your desired outcomes, it will transform your body to a spectacular amount.

The prominent areas that differ a male from a female body are the buttocks, chest and hips.

Body contouring does not necessarily need prior testosterone therapy, though being on testosterone medications will help in the masculinization of the body.

Things to consider before the surgery

The skeletal frame of a person highly determines the body shape and distribution of fat and muscles. The most that surgeries can do is to transform the feminine structure to a masculine frame, but before your expectations skyrocket, do bear in mind that there is a significant difference between a person assigned female by birth and those who were born a male. However, there is a guarantee for improved self-esteem and self-worth.

Body contouring to masculinize the body is not a weight loss program; rather it is a sculpting treatment. You will need to check your weight and keep it ideal before the surgery for maximum results.

There are potential risks and complications involved in each procedure. You can avoid them by paying attention to pre-op and post-op instructions. Your surgeon will run a full evaluation before you decide on the approaches to get a male body.

Eligibility for the Body Masculinization Surgery

• Non- smoker, or should have given up smoking at least two weeks before the surgery
• Should be 18 years and above
• The patient’s weight must be proportionate to their frame
• Should have taken hormone therapy for at least one year

What is the ideal male physique?

There is no single preference for the ideal male physique, but the general features that define the masculinity of a person are composed of broad shoulders, well-defined jaws, strong chest, and less fat distribution to the buttocks and hips. All the mentioned attributes can be summed up to a V-shaped body.

The challenge to obtain a natural V-shaped masculine body for trans-men is challenging, and the road to this structure involves many surgeries. Besides surgery, exercises that will build muscles around the shoulder and upper part of the torso are some ways to get a body close to the desired V-shape.

Fat distribution is different between a man and a woman. While women carry fat more on the hips, thighs and buttocks, men tend to distribute fat to the upper part of their body.

This female pattern of weight gain and fat distribution makes it necessary for a transgender man to undergo several masculinization surgeries and therapies.

Focus areas in FTM Body Contouring

The areas commonly treated to obtain the much desired V-shape body are:

1. Upper torso (chest and back)
2. Abdomen (tummy tuck)
3. Hips
4. Flanks
5. Buttocks
6. Thighs (inner and outer)

Methods for Body Masculinization

Mastectomy: Removing breasts to flatten the chest is called mastectomy. This may involve procedures like double incision for large breasts and keyhole incision for smaller breasts. A small amount of fat is left for the natural appearance of the male chest.

Women have larger areolas and nipples that protrude more than men. Nipple grafting is included with this surgery where the areola and nipples are resized and reshaped.

Abdominoplasty: Also known as a tummy tuck, this procedure aims to make the abdomen firmer and thinner. Excess skin and fats are removed from the lower and middle abdomen, tightening the muscles of the abdominal wall.

There is another way to the tummy tuck procedure called mini-abdominoplasty, usually chosen by patients having a small amount of excess skin below the navel.

Liposuction: Body contouring using liposuction is a safe procedure which removes fats from target areas using suction methods. For the upper torso, liposuction is treated on underarms, flanks or love handles, thighs and other areas that need contouring to create a typical male body.

Liposuction is usually performed on an outpatient setting under general or local anesthesia. This procedure leaves almost no scars as the incisions are small. One surgery can treat multiple regions. Often, liposuction is combined with abdominoplasty for the thighs and hips. Surgeons usually use this combination to produce good results.

Buttocks: In the female body, fat is distributed mostly to the buttocks adding curves. Liposuction is used to accomplish the reduction of prominent female curves from the buttocks to create a flatter and firmer masculine buttock. Removing the excess fat from the buttock will emphasize in creating the V-shape body.

Recovery and Post-Op

For the first week, you will be required to take rest. Pain and discomfort after the surgery will be managed with prescribed medications. You will be wearing a compression garment for two to four weeks.

Resuming work can be expected after a week, provided you avoid strenuous work and heavy exercise. By six weeks you can expect to resume full activities.

Risks and complications

• Your body may react to the use of anesthesia
• Since large incisions are made, infection of the wound site is inevitable. But with proper care and prescribed antibiotics, they can be managed.
• Incisions will leave permanent scarring
• After the surgery, risks of hematoma and seroma can occur
• If the healing is taking a long time, you may experience skin ischemia or necrosis
• Contouring may either give you a desirable result or may leave asymmetries, but you can hope for them to diminish over time
• A common problem after surgery is the numbness of tissues surrounding the wound region, which is free from pain.

FAQS

Can I go for body contouring surgery after top surgery?

A: Yes. In fact, body contouring can be an option at any point. This approach can be made before, after and during a top surgery under the same anesthesia.

What is the right age for body masculinization surgery?

A: There is no particular age to have this surgery, provided you are 18 years and above.

I have the habit of smoking, when should I quit before and after the surgery?

A: You should quit smoking at least two weeks before and after the surgery. Better if you take advantage of the surgery instructions to quit smoking for good.

How many days do I have to stay in the hospital after the surgery?

A: Depending on the procedure, it could be an outpatient one where no hospital stay is recommended or a more invasive one with anywhere from a couple of days to a couple of weeks of in-hospital stay.

References:

http://www.rumergendersurgery.com/body-masculinization/

https://thetranscenter.com/transmen/body-masculinization-procedures/

https://www.ftmsurgery.net/body-masculinization-surgery/

Richard Troy

Medical Blogger committed to accuracy, I am passionate about delivering my readers critical insights into the medical field.
Former paramedic, instructor and medical school student.
You can read more about me in the dedicated section of the website.

www.medtravel.asia/about-richard-troy-medical-blogger/

The post FTM Masculinization Procedures: Body Contouring for Transgenders appeared first on MedTravel Asia.

Hair grafting or hair transplant for trans-men is a challenging procedure among the top surgeries which gives a satisfactory result in the appearance. It is usually done to add masculinity by changing the hairline or allowing facial hair.

This procedure is done through follicular unit extraction (FUE) and follicular unit grafting (FUG). It involves transplant of each microscopic graft into small recipient areas measuring not more than 0.8 mm.

Female-to-male hair restoration may include creating masculine sideburn, eyebrow, goatee, and beard. Getting a hair transplant will not only change your appearance, but it will also develop a male pattern of natural hair growth and balding.

Difference between Male and Female Hair

While women are known to have a higher hairline, men tend to have an M shaped hairline.

The hairline in male and female are different in so many ways like the balding pattern, flow of hair and even the texture. There are intricacies when it comes to hair grafting or hair restoration in a sex reassignment therapy.

Male hair loss is noticeable with a receding hairline which may or may not result in complete baldness. On the other hand, women lose their hair diffusely, which happens more on the crown rather than the hairline. Thinning of hair is more progressive in women exposing the scalp when the hair is tied.

Types of Hair Grafting in FTM Masculinization Procedures

Facial hair: Most of the time, the virility of a man is assumed by the facial hair he has. While undergoing an FTM sex change, you may want the hairy facial feature of men in the form of a beard, mustache or sideburns.

While a testosterone therapy may initiate on facial hair growth, the result is usually sparse and appears underdeveloped. A facial hair transplant will give you thicker facial hair. Your surgeon will devise a natural pattern to provide you with a natural looking mustache, goatee, beard, and sideburns.

The transplant designs are typically individualized. Depending on your choice, the hair transplant will vary from thick to a diffused beard. There are some risks involved in hair transplant especially in the center of the lower lip, also known as soul patch.

Usually, the procedures require 400 – 500 grafts for the beard on one cheek, 250 grafts for one sideburn, and 500 – 700 grafts for a goatee.

Hairline: Masculinization of your hairline will involve changing your high hairline to an M-shaped hairline which has upper corners and a downward bend in the middle.

Your surgeon will use methods like follicular unit extraction (FUE) where hair follicles will be harvested from the back of your head, and it will be grafted to the front to form a masculine hairline. Other methods include the Artas Robotic system and linear methods.

Chest hair: If having a hairy chest is masculine for you, a hair transplant can work on your body hair. While some go for chest hair for virility, there are other reasons like covering scar areas on the chest region after chest surgery.

Chest hair transplant requires a several grafts ranging from 1200 to 1500 grafts; it may even go up to 3200 grafts for more coverage.

Eyebrows: For the eyebrows, each side will require 225 to 325 grafts. The direction and angle of the eyebrows will matter for a natural aesthetic result. The outcome would be fuller eyebrows that are more arched than a typical feminine pair of eyebrows.

Preparation for Surgery

• Maintaining a healthy physical regime before going for top surgery is essential. Keep a balanced diet and keep your weight at the right
• Get emotional support. Going through a sex change is a significant step, and it will affect your life.
• Quit smoking and alcohol at least three weeks before the surgery.

Recovery and Post-Op Care

Hair grafting surgery is done under local anesthesia. After the surgery, you will need antibiotic and painkillers as per your doctor’s prescription.

Do not wet the treated area for a week following the graft to set it properly. You will notice hair growth within four months, and after a year you will see the final results. Maintenance after hair grafting will be regular trimming.

References

https://www.dryateshairscience.com/transgender-hair-restoration-sugery

https://www.atlantahairsurgeon.com/hairline-revisions/masculized/

Richard Troy

Medical Blogger committed to accuracy, I am passionate about delivering my readers critical insights into the medical field.
Former paramedic, instructor and medical school student.
You can read more about me in the dedicated section of the website.

www.medtravel.asia/about-richard-troy-medical-blogger/

The post FTM Masculinization Procedures: Hair Grafting in transgenders appeared first on MedTravel Asia.

Phalloplasty is a broad medical term that could indicate many different surgical procedures; it could be a plastic or reconstructive surgery in the case of defects or trauma to the penis of cisgender male patients, or it could be an aesthetic procedure when the goal of surgery is improving some characteristics of the penis in cisgender males, or it could be a reconstructive procedure in the case of FtM transgender patients in which case it is also known as bottom surgery or penile reconstruction.

Indications for the phalloplasty

There are many possible reasons why a phalloplasty is performed. In the cisgender male it is generally done in case of:

• Aphallia or penile agenesis
• Micropenis
• Epispadias
• Ipospadias
• Trauma to the penis to a variable extent
• Penile tumors that need to be excised
• Congenital penile curvature
• Cosmetic penis enlargement

In cisgender males the phalloplasty is any surgical procedure of the penis with the goal of modifying it or reconstructing it, both to solve congenital problems and to solve acquired problems; moreover it can also indicate an aesthetic surgery with the goal of increasing the penis shape, size and/or length. This last option is seeing an increase in demand year after year.

In FtM transgenders the phalloplasty represents uniquely the penile reconstruction surgery with the goal of creating a neo-penis and make the gender identity of the patient congruent with their physical appearance; the phalloplasty represents a treatment for gender dysphoria and facilitates social inclusion.

In this blog post we will specifically cover the phalloplasty for transmen undergoing sex reassignment surgery (SRS).

Criteria for the phalloplasty procedure

The Standards of Care 7th edition of the World Professional Association for Transgender Care (WPATH) set the following criteria to have access to the phalloplasty procedure:

• Persistent and well documented diagnosis of gender dysphoria
• In full possession of one’s faculties. Able to make a fully informed decision and to give consent for treatment.
• Age of majority in a given country.
• The absence of absolute medical contraindications (medical conditions which would make it too risky to perform the surgery).
• At least 12 continuous months of masculinizing hormone replacement therapy
• At least 12 continuous months of living in a gender role that is congruent with their gender identity.

These criteria, especially the last point, are set to allow the patient to experience and adapt their gender role, before they undergo an invasive and irreversible surgery and to minimize risks and maximize post-op satisfaction.

One more pre-requisite before undergoing a phalloplasty is the elimination of all hair on the donor area by using a laser or IPL device for permanent hair removal; this is because this area will later be used for the creation of the neo-penis and in some cases of the neo-urethra, so it needs to be hairless.

Goals of phalloplasty in FtM transgender patients

From the patient’s point of view, the goals of the phalloplasty are generally the following:

• The creation of an aesthetically pleasing and accurate neo-penis which doesn’t raise doubts in social settings
• To be allowed to void while standing
• To be allowed to have penetrative sexual intercourse
• To have tactile and erogenous sensation in the neo-penis
• To minimize the scarring and loss of function in the donor area or other complications
• To undergo sex reassignment surgery in a single surgical session

There is also the added goal from the surgeon’s point of view of finding a technique which is simple, with low risks and complications rate and which is easily reproducible.

Since 1936, the year when the first phalloplasty was performed, this surgery evolved considerably trying to reach all the objectives listed above; a final and unique solution though hasn’t yet been reached, with no technique superior to all the other available. In particular, all surgeons concur that for now a satisfactory result cannot be achieved by performing a single surgical procedure.

The phalloplasty is indeed completed over several surgical sessions to cover distinct phases of the reconstruction, and not in a single day and surgery.

During the first stage, the vaginectomy, the phalloplasty and the scrotoplasty are usually performed. The urethroplasty or urethral lengthening can be done during the first step, could be split into the first and second step, or could be done during the second step. The second stage might include part or all of the urethroplasty and the balanoplasty (surgical reconstruction of the glans of the penis). The testicular implants might be inserted in the second step or in the third one. The third stage could include the insertion of the testicular implants as well as the erectile implant for the neo-penis, when requested by the patient. During the second step often some revisions or touch ups are performed such as in case of complications to the neo-urethra, or to improve the aesthetics of the neo-penis. The whole 3-stage procedure might require as long as two years to be completed (post-op recovery from the surgeries included).

The results of the phalloplasty are variable and depend upon multiple factors such as the anatomy of the patient, the surgeries already undergone and the ones that will be performed with the phalloplasty, the surgical technique and the skills and experience of the surgeon.

The surgical techniques in FtM sex reassignment surgery (SRS)

Besides the metoidioplasty procedure or meta which we covered in another blog post, there are multiple surgical techniques to perform the sex reassignment surgery on transgender males all of which fall into the category of phalloplasty. None of these procedures is the best one available due to better functional and aesthetic outcomes or lower risks and complication rates. Hence it is an individual choice which could be influenced by specific anatomical characteristics of the patient, by aesthetic outcomes (what location will have a visible scar), by surgical considerations, by financial considerations (different techniques have different costs) or by the chosen surgeon as each surgeon usually performs a single technique which he prefers. Among the many surgical techniques developed over the years and available as of today, there are:

1. ALT Phalloplasty: pedicled anterolateral thigh flap phalloplasty or anterolateral thigh free flap phalloplasty.
2. RFF Phalloplasty: radial forearm free flap phalloplasty.
3. Double Flap or Combined Flap Phalloplasty: RFF and ALT combined techniques.
4. Suprapubic flap or abdominal flap or Pryor’s technique phalloplasty
5. Bird-Wing Abdominal Flap Phalloplasty
6. FFF Phalloplasty: fibula free flap phalloplasty
7. Kim’s Phalloplasty: conjoined bilateral pedicled groin flap phalloplasty
8. MLD Phalloplasty: musculocutaneous latissimus dorsi free flap phalloplasty
9. Reinnervated MLD Phalloplasty: reinnervated musculocutaneous latissimus dorsi free flap phalloplasty

All of these techniques have the base goal of harvesting enough tissue from the donor area with the right characteristics: innervation, vascularization, thickness, easiness to harvest, dimensions, etc. This harvested tissue, known as flap, is then rolled-up in a tubular shape and will form the neo-penis. A second strip of tissue, with different characteristics than the first one and smaller in width, is tubularized to form the neo-urethra which will be used for urethral lengthening. At this point there will be two tubular structures one inside the other. With the surgical microscope the surgeon will anastomose (medical term that means conjoin) the arteries, veins and nerves of this newly created structure from the donor area with the previously dissected arteries, veins and nerves of the recipient area to provide vitality and sensation to the tissues. The neo-urethra is anastomosed with the existing urethra to finalize the urethral lengthening.

As stated already, the transplanted nerve present in the flap from the donor area are connected to nerves which are present in the recipient area. Based on the surgeon and on the technique employed these connections might vary. In general, there are two nerve connections available: one is the ilioinguinal nerve to provide tactile sensation, the other is made with one of the two branches of the dorsal nerve of the clitoris to provide erogenous sensation. The second dorsal nerve will be left intact and the clitoris itself is buried at the base of the neo-penis so that the manipulation of the phallus will stimulate the clitoris which is still innervated.

The passages above are the ones usually performed and common to all the phalloplasty procedures; below we will describe the features of the various surgical techniques.

1. ALT Phalloplasty: pedicled anterolateral thigh flap phalloplasty or anterolateral thigh free flap phalloplasty

The flap harvested following this technique includes the skin, the adipose tissue and the fascia, with blood supplied by the lateral femoral circumflex artery and innervation provided by the lateral cutaneous nerve of the thigh.

Due to the complex path followed by the blood vessels involved in this surgery, which varies among individuals, this surgical technique could be difficult to perform.

A determining factor when choosing this procedure is the thickness of the skin and of the adipose layer which needs to be evaluated by the surgeon: an excessive thickness is contraindicated for this surgery and also precludes the use of the harvested tissue for the creation of the neo-urethra. Limited thickness will instead guarantee good tactile sensation to the transplanted flap.

Advantages of the ALT phalloplasty:

• The donor area is rarely exposed, and the scar is easily hidden under clothing.
• The broad donor area allows for large dimension flaps.
• The color of the donor area is similar to that of the recipient area, improving the aesthetic result.
• If pedicled flap is used, the surgery is faster and lasts on average 90 minutes less than when free flaps are used.
• The donor area is not subject to loss of functionality post-op

Disadvantages of the ALT phalloplasty:

• It is not indicated for patients with thigh skin too thick or with too much adipose tissue (>2cm)
• The flap is generally thicker; hence it is harder to shape it.
• It’s more complex due to the variable disposition of the blood vessels.
• The sensation of the neo-penis is inferior than that obtained with other techniques.
• There’s a higher urethral complication rate compared to other techniques.

2. RFF Phalloplasty: radial forearm free flap phalloplasty

The free radial forearm flap phalloplasty is considered to be the gold standard technique by some surgeons in the context of female to male sex reassignment surgery.

The tissues are harvested from the non-dominant arm. The flap includes the radial artery, the cephalic and basilic veins, and the lateral and medial cutaneous nerve of the forearm.

This procedure is not indicated for all of the patients: the screening is done by performing the Allen test to assess arterial blood supply of the hand and predict post-op arterial insufficiency.

Advantages of RFF Phalloplasty:

• Better sensation due to the anatomical characteristics of the flap.
• Reduced thickness of the donor area allows for easier shaping of the neo-penis

Disadvantages of RFF Phalloplasty:

• Partial loss of function (less strength) of the hand and forearm where flap was harvested
• Free flaps have higher risk of failure when compared to pedicled flaps
• The scar is less easily concealable under clothing
• The scar on the forearm is very peculiar to this surgery and many patients consider it a stigma, opting for other surgical techniques.
• It requires a skin graft to the donor area from the thigh or the glutes.

3. Combined ALT/RFF Phalloplasty

The combined ALT/RFF phalloplasty is a modification of the ALT technique which utilizes a flap harvested from the thigh to create the neo-penis and a smaller flap harvested from the forearm to reconstruct the neo-urethra.

Advantages of the combined ALT/RFF Phalloplasty:

• The forearm flap has characteristics that make it more suitable for urethral reconstruction.
• It is less invasive on the forearm, leaving just a rectilinear scar.
• Shows less risk of urethral complications
• The use of a pedicled ALT flap lowers the risk of tissue necrosis

Disadvantages of the combined ALT/RFF Phalloplasty:

• It is a more complex procedure with more time spent in the OR when compared to other techniques.

4. Suprapubic flap or abdominal flap or Pryor’s technique phalloplasty

The suprapubic flap phalloplasty is performed by harvesting a pedicled flap of about 11cm in height and 12cm in width measured from the base of the clitoris; this flap includes the skin and derma up to the fascia that covers the rectus abdominis muscle. These tissues are then shaped and shifted into position.

Advantages of Pryor’s technique phalloplasty:

• Pedicled flaps don’t require vascular microsurgery and have a lower rate of complications
• The scar is less visible and usually well tolerated by the patients
• Less complications to the donor area
• Less time in the OR and faster post-op recovery
• The hysterosalpingo-oophorectomy can be performed at the same time and using the same incisions.
• Easier to perform

Disadvantages of Pryor’s technique phalloplasty:

• Worse aesthetic result when compared to other techniques
• It requires a second stage procedure if the patient wants urethral lengthening too.
• Being a pedicled flap, tactile sensation is preserved, but there is no erogenous sensation which relies uniquely on clitoral stimulation that will be buried or hidden at the base of the neo-penis.
• High risk of urethral complications if the urethroplasty is performed during the same stage as the phalloplasty

5. Bird-Wing Abdominal Flap Phalloplasty

Bird-Wing pedicled flap phalloplasty was developed as an alternative to other techniques to minimize the scarring of the donor area and to improve and speed up the post-op recovery. The scar resulting from this surgery is a straight horizontal line in the lower abdomen.

Advantages of the Bird-Wing Abdominal Flap Phalloplasty:

• Easier to perform and faster, doesn’t require microsurgery
• Less visible scar
• Faster healing
• Less post-op complications

Disadvantages of the Bird-Wing Abdominal Flap Phalloplasty:

• Does not include the urethroplasty. If the patient wants the urethral lengthening it need to be performed in the second stage.
• There is no erogenous sensation of the neo-penis, only tactile sensation is preserved.

6. FFF Phalloplasty: fibula free flap phalloplasty

Fibula free flap phalloplasty is an alternative technique that was developed for those who don’t want to have a visible scar on the forearm. It is an osteocutaneous free flap; it includes the peroneal artery and vein, the lateral sural cutaneous nerve and part of the bone tissue of the fibula.

The harvested bone is anchored to the pubic bone providing rigidity, while the branch of the sural nerve is connected to one of the two branches of the dorsal nerve of the clitoris with the possibility, but not certainty, to gain erogenous sensation of the neo-penis; the clitoris and the other dorsal nerve remain intact to preserve the physiological erogenous sensation

Advantages of FFF phalloplasty:

• Less visible scar
• Does not require a penile implant
• In some cases, there is erogenous sensation of the neo-penis

Disadvantages of FFF phalloplasty:

• The transplanted bone can fracture, curve or can be resorbed over time
• The permanent rigidity can be difficult to hide and be a source of discomfort
• There can be functional limitation and complications in the donor area
• It could require revision surgery to improve the aesthetics

7. Kim’s Phalloplasty: conjoined bilateral pedicled groin flap phalloplasty

Dr. Kim’s phalloplasty was developed by Dr. Kim Jin Hong, a South Korean urologist who specialized in urogenital reconstructive surgery under Prof. Sava Perovic in Belgrade.

It utilizes two bilateral pedicled inguinal flaps harvested to create the neo-penis. It is an easier, faster and less expensive technique when compared to others. The procedure is split into 3 steps spaced at least 3 months apart from each other’s: the phalloplasty, scrotoplasty with testicular implants are performed during the first stage; the second stage is the implantation of the erectile device; during the third stage, the vaginectomy and urethroplasty are performed.

Advantages of Kim’s phalloplasty:

• It costs about 35% less than other procedures
• The scars are less visible and easily hidden under clothing or swim trunks.

Disadvantages of Kim’s phalloplasty:

• The size of the neo-penis depends uniquely upon the dimensions of the patient (the size of the donor area)
• Semi-rigid malleable implants can be implanted, but the inflatable ones can’t.
• The size of the penis is smaller than with other techniques, averaging 10,5cm in length.

8. MLD Phalloplasty: musculocutaneous latissimus dorsi free flap phalloplasty

MLD phalloplasty utilized a flap harvested from the dorsal region which includes part of the latissimus dorsi muscle, thoracodorsal nerve and vessels. Only a strip of muscle tissue is harvested which will be wider the thinner is the patient. The resulting scar is long and linear if the skin is sufficiently elastic to be sutured and closed after harvesting the flap. The urethroplasty is performed at a later stage at least 6 months apart from the first one. The nerve connection is made between a sensory nerve in the recipient area with a motor nerve from the donor area.

Advantages of the MLD phalloplasty:

• Better sensation than with inguinal or abdominal flaps
• Good aesthetic result and good dimensions of the neo-penis
• Good anatomical characteristics of the donor area (dimensions, volume, neurovascular pedicle length)
• Less risk of dyschromia of the skin and tissue resorption than with fasciocutaneous flaps.
• If the skin of the donor region is prepped at least 3 months in advance with massages and topical application of creams to improve the elasticity, it is possible to suture the donor area leaving just a linear scar

Disadvantages of the MLD phalloplasty:

• Worse sensation than with RFF technique
• Not indicated in overweight patients due to the increased thickness of the flap
• Not much erogenous sensation; tactile sensation that improves over time

9. Reinnervated MLD Phalloplasty: reinnervated musculocutaneous latissimus dorsi free flap phalloplasty

The reinnervated MLD phalloplasty is a variation of MLD phalloplasty that allows the patients to have penetrative sexual intercourse without a penile implant.

The difference with the ordinary MLD is that there is an incision in the medial region of the thigh to expose both a branch of the obturator nerve that innervates the gracilis muscle and a branch of the medial circumflex femoral artery.

The harvested flap has ¼ of its length exposed without skin and subcutaneous tissues, just the muscle, while the other ¾ have the ordinary characteristics. This exposed side allows the surgeon to anchor the harvested muscle to the fascia of the rectus abdominis. A small subcutaneous tunnel is created in the inguinal region to allow for the passage of vessels and nerve of the flap that will be connected with those dissected from the thigh.

The connection between the dorsal motor nerve and a motor nerve from the thigh allows for voluntary contraction of the neo-penis. After surgery, the patients undergo a rehabilitation protocol with muscle electrostimulation at least 3 days a week for at least 6 months; once voluntary control of the muscle is gained the physical therapy is continued until contraction and control are satisfactory to the patient.

In one study with 22 patients, 19 of which followed-up, and who underwent this procedure between 2001-2005, 95% (18) were able to contract the muscle and experience a voluntary erection.

Advantages of the reinnervated MLD phalloplasty:

• The erection is possible without an implant

Disadvantages of the reinnervated MLD phalloplasty:

• Although the erection is possible, it’s not guaranteed the ability to have penetrative sexual intercourse.

Risks and complications of the phalloplasty

Differently from other procedures, the phalloplasty as a high rate of post-op complications and high risks. High is also the post-op satisfaction when the surgery is successful, reason for which although the high risks many patients decide to undergo the procedure.

It is a relatively new surgical technique, extremely complex and still not widely practiced around the world; steps forward and new developments are expected with overall improvements and lower risks.

Different techniques have different risks and complications. Different surgeons practicing the same technique have different statistics on complication rate, success, and satisfaction.

As any surgical procedure, among the risks there are the infections, hemorrhages, tissue damage and pain. Urethral complications with fistulae and strictures are quite common when an urethroplasty is performed. Lack of sensation, partial or total necrosis, dissatisfaction due to the aesthetics, shape or dimensions are among the other possible complications.

The donor area can experience complications too, with reduced strength and/or mobility, pain, loss of sensation, extended scarring, infections, slow healing, adhesion formation.

Risks and complication rates specific to the technique and chosen surgical team will be thoroughly explained during consultation.

Accessory surgeries combined with the phalloplasty of performed before or at later stage in transgender patients

1. Hysterosalpingo-oophorectomy
2. Vaginectomy
3. Urethroplasty or urethral lengthening
4. Scrotoplasty
5. Testicular implants
6. Balanoplasty or glans reconstruction
7. Coronaplasty or reconstruction of the penis crown
8. Cosmetic tattooing of the glans
9. Penile implant

Urethroplasty in transgender patients who undergo phalloplasty

The urethral lengthening can be performed in different ways and at different stages, depending upon the surgeon.

• Total vascularized urethroplasty: it is performed using tissues obtained from the harvested flap (such as the ALT or RFF flaps), or from tissues harvested from the labia minora, labia majora, vaginal mucosa or from the groin.
• Total non-vascularized urethroplasty: this procedure utilizes a graft harvested from the oral mucosa (higher rate of stenosis and fistulae).
• Partial urethroplasty: when the urethra is lengthened up to the base of the neo-penis instead of the tip (lower rate of complications, but the patient won’t be able to void while standing).

Balanoplasty and coronaplasty or reconstruction of the glans and crown

These two procedures improve the aesthetics of the neo-penis and can be performed either in the first stage or in the second stage of the multistage sex reassignment surgery.

These procedures create a penis similar in look to a circumcised penis and with the cosmetic tattooing of the glans a great degree of realism can be achieved.

There are many different techniques that employ the use of flaps or grafts harvested from different anatomical structures to modify the aesthetics of the tip of the penis.

Penile implants for FtM transgender patients

The penile prosthesis implantation is generally, but not always, the last surgery performed in the multi-stage phalloplasty; it is usually done at least 6-12 months after the penile reconstruction, when the neo-urethra and neo-penis healed and the patient recovered all possible sensation in the area. Post-op recovery time is about 6-8 weeks after which the patient should be able to have sexual intercourse.

There are mainly three categories of penile implants:

1. Non-hydraulic penile implants (non-inflatable), semi-rigid, malleable or non-malleable.
2. Hydraulic bi-component penile implants (inflatable, 2 pieces)
3. Hydraulic tri-component penile implants (inflatable, 3 pieces)

Biologic implants that were studied over the years belonged to the first category: bone grafts from the fibula or ulna or cartilage grafts. This type of implant is almost never placed anymore due to the inconvenience of having a constant erection, the tissue resorption that happens over time and the risk of fracture, perforation and tissue damage.

To the first category belong also other non-inflatable implants: semi-rigid and malleable prosthesis; they are made of one or two shafts of stainless steel covered in silicone. They provide enough rigidity to allow for penetrative sex but are always semi-rigid; they can be bent in various shapes to imitate the flaccid or erect state of the neo-penis. The advantage of this type of implant is that they are easy to use, they just need to be bent by hand and are ready for use. The surgery to implant them is the easiest, they are the least expensive and the absence of mechanical parts make them long lasting, about 20 years.

Bi-component inflatable implants are made up of one or two cylinders that are implanted in the shaft of the penis, one reservoir filled with saline solution at the base of the cylinders, and one pump and one release valve that are placed in the scrotum.

To have an erection, the patient needs to squeeze the pump a couple of times to pump the saline solution into the cylinders and achieve an erection. To get back to flaccid state, the patient needs to gently bend the penis downwards and this action will activate the valve and make the fluid drain back into the reservoir in the scrotum. The advantages of this implant are that it is easy to use, and it is the least expensive among the inflatable implant category.

The hydraulic tri-component penile implants are made up of three pieces. The difference with the bi-component ones is that the reservoir is not placed at the base of the cylinders, but it is located in a pocket created in the lower abdomen allowing for greater volume of fluid. It works similarly to the 2-pieces implants, but to return to the flaccid state there is a mechanism to press on the pump. The advantages of the 3-piece implant are that it is easy to use, the larger pump in the scrotum allows for faster erections, more rigidity, better flaccid state as well as less pressure on tissues at rest, lowering the risk of injuries. The presence of a number of mechanical parts makes them more susceptible to mechanical issues, with devices lasting up to 10-15 years, but with malfunctioning reported since the third year.

For the placement of the erectile implant it might be necessary to remove one testicular implant or in case of too little scrotal volume it might be necessary to use a tissue expander before implanting the device.

The main challenge in the implant surgery is that contrary to cisgender males, transmen lack some anatomical structures such as the tunica albuginea which is the perfect housing for the cylinders: it protects the surrounding tissues, keeping the cyilinders in place and avoiding injury. Moreover, the lack or limited sensation in the neo-penis increases the risk of tissue damage, especially at the tip of the penis as without feeling pain the patient would not know about an injury. The vascularization of the flap that makes up the neo-penis is inferior to that of a natural tissue, hence the healing processes are slower too, with an increased risk of infection. Lastly, on the contrary of cisgender males who usually require such implant at a later age, transmen are usually younger and most likely more sexually active, which increases the risk of incurring damage.

To avoid all of these issues some surgeons opt for the use of tissues or materials to encase the implants and/or to anchor them to the pubic bone, to recreate a sort of artificial tunica albuginea, but more resistant.

As the phalloplasty, the erectile implant surgery still has ample room for improvement. At the moment, the complication rate needing a revision surgery is about 25-75%. Infection rate is about 8-15% and to lower that risk now they soak the prosthesis in antibiotics before implanting them. Despite the high complication rate, a lot of patients still request this surgery, due to the high post-op satisfaction.

About flaps and grafts

What is the difference between free flaps and pedicled flaps?

One of the differences among the various phalloplasty procedures is about the type and location where the flap is harvested.

Pedicled flaps are pieces of tissue that preserve a connection with the donor area; this connection provides blood flow and sensation, so they do not need any anastomosis. The flaps are simply rotated and shifted into position, keeping their original innervation and blood supply.

Free flaps are tissues harvested and completely detached from the donor area and then transplanted into the recipient area. They need to be connected to blood vessels and nerves in the recipient area to keep vital and regain sensation.

Pedicled flaps are more reliable, meaning they have lower risks of complications or total failure; partial failure is still possible and depends from the shape and type of the flap. Free flaps instead are an all-or-nothing procedure: it is either a success or a total failure, with a failure rate of about 1-5%.

What is the difference between musculocutaneous flaps, fasciocutaneous flap and osteocutaneous flap?

Another difference between flaps is related to the type of tissues that are harvested from the donor area.

Musculocutaneous flaps consist of the skin, subcutaneous tissue, the underlying fascia and part of the muscular tissue; one of the main features of this type of flap is that the blood supply doesn’t come from a cutaneous artery, but from deeper arteries that supply blood to the muscle and that from here propagates towards the upper layers of tissue up to the skin. The increased thickness makes it more rigid in consistence and it also provides increased resistance against bacterial infections (about 100 times more resistant than a fasciocutaneous flap).

What is the difference between grafts and flaps?

Grafts are classified based on what type of tissue they are made of: it could be the skin, like in the case of burn victims who get skin grafts; it could be bone as it often happens in maxillo-facial surgery and dentistry; it could be a cartilage graft such as in nose bridge augmentation using a rib cartilage graft; or it could be fat tissue as in fat grafts used to reshape areas in cosmetic surgeries; and so on, it could be nerves, tendons, etc.

The difference with flaps is that grafts do not possess their own blood supply: they rely on the recipient area to receive nutrients and survive.

Sources

• Double flap phalloplasty in transgender men: Surgical technique and outcome of pedicled anterolateral thigh flap phalloplasty combined with radial forearm free flap urethral reconstruction.
  Van der Sluis WB, Smit JM, Pigot GLS, Buncamper ME – Microsurgery Journal, Mag 2017
• Pedicled pubic phalloplasty in females with gender dysphoria.
  Bettocchi C, Ralph DJ, Pryor JP – British Journal of Urology, Gen 2005
• “Bird-Wing” abdominal phalloplasty: A novel surgical technique for penile reconstruction.
  Bajpai M – Journal of Indian Association of Pediatric Surgeons, Mar 2013
• Musculocutaneous latissimus dorsi flap for phalloplasty in female to male gender affirmation surgery.
  Djordjevic ML, Bencic M, Kojovic V, Stojanovic B, Bizic M, Kojic S, Krstic Z, Korac G – World Journal of Urology, Gen 2019
• New technique of total phalloplasty with reinnervated latissimus dorsi myocutaneous free flap in female-to-male transsexuals.
  Vesely J, Hyza P, Ranno R, Cigna E, Monni N, Stupka I, Justan I, Dvorak Z, Novak P, Ranno S – Annals of Plastic Surgery Journal, Mag 2007
• Techniques and considerations of prosthetic surgery after phalloplasty in the transgender male.
  Kang A, Aizen JM, Cohen AJ, Bales GT, Pariser JJ – Translational Andrology and Urology Journal, Giu 2019
• A New Technique for Coronaplasty in Penile Reconstruction.
  Sommeling CE, De Wolf EJ, Salim A, Monstrey S, Opsomer D, Claes K, D’Arpa S – Journal of Sexual Medicine, Giu 2018
• Management of Gender Dysphoria – A Multidisciplinary Approach
  C Trombetta, G Liguori, M Bertolotto – Springer, 2015
• Principles of Transgender Medicine and Surgery – 2nd edition
  Ettner R, Monstrey S, Coleman E – Routledge 2016
• Transgender Medicine – A multidisciplinary Approach
  Poretsky L, Hembree WC – Springer 2019

Richard Troy

Medical Blogger committed to accuracy, I am passionate about delivering my readers critical insights into the medical field.
Former paramedic, instructor and medical school student.
You can read more about me in the dedicated section of the website.

www.medtravel.asia/about-richard-troy-medical-blogger/

The post FtM Bottom Surgery: phalloplasty appeared first on MedTravel Asia.

The metoidioplasty, also known as metaoidioplasty or meta, is a plastic and reconstructive surgery for female to male (FtM) sex reassignment. It is also referred to as bottom surgery and is one of the two available options for gender reassignment in the FtM transgender patient and for the creation of a neo-penis, the other being the phalloplasty procedure.

The goal of the metoidioplasty is that of making congruent the physical appearance of the patient with their gender identity; it is a surgery capable of preserving both the tactile and erogenous sensation of the tissues as well as allowing for a natural erection.

The metoidioplasty exploits the clitoral hypertrophy induced by hormone replacement therapy with testosterone to transform the clitoris into a neopenis. If paired with the urethroplasty procedure, the metoidioplasty allows the patient to void while standing facilitating the inclusion of the patient in social settings and public places and for this reason, even though it generally doesn’t allow for penetrative sexual intercourse, it is a satisfactory surgery for most of the patients; only 1% of the patients report post-op dissatisfaction and request a revision surgery to improve the desired results by undergoing a phalloplasty.

The metoidioplasty usually is not a standalone procedure but is combined with other surgeries to minimize the number of general anesthesia the patient will undergo and minimize the number of hours spent in the operating room by the patient to complete the FtM transition. The surgeries that can be paired with the metoidioplasty are the bilateral hysterosalpingo-oophorectomy, the vaginectomy, the scrotoplasty, the urethral lengthening and sometimes the bilateral subcutaneous mastectomy. Moreover, the lipectomy or liposuction of the mons pubis can sometimes be performed as well at the same time, when its excessive protrusion would otherwise compromise the aesthetic results of the metoidioplasty.

Criteria for the metoidioplasty

The Standards of Care 7^th edition of the World Professional Association for Transgender Care set the following criteria to have access to the metoidioplasty procedure:

• Persistent and well documented diagnosis of gender dysphoria
• In full possession of one’s faculties. Able to make a fully informed decision and to give consent for treatment.
• Age of majority in a given country.
• The absence of absolute medical contraindications (medical conditions which would make it too risky to perform the surgery).
• At least 12 continuous months of masculinizing hormone replacement therapy
• At least 12 continuous months of living in a gender role that is congruent with their gender identity.

Besides the above criteria which are set by international expert in the field of transgender medicine to avoid premature decisions when they involve invasive and non-reversible surgeries, there are also further requirements which are very important for a successful outcome and which are strictly of medical and surgical nature:

• The clitoris has to measure at least 2 cm in length
• The patient should not be obese
• The labia minora and clitoral skin should be physiologically developed to allow for use as grafts such as in urethral lengthening or as skin grafts.
• For optimal results, it is advised to wait at least 24 months from the start of hormone replacement therapy with androgens before undergoing surgery; this allows for maximum development (hypertrophy) of the clitoris before the procedure is performed.
• It might be advised by the surgeon the use of a dihydrotestosterone gel for at least 3 months before surgery, to be applied topically two times a day; the use of vacuum devices might be advised too as the mechanical traction they exert on tissues can help in maximizing the development of the clitoris.

The different surgical techniques in metoidioplasty

The metoidioplasty in female to male (FtM) sex reassignment surgery (SRS) can be performed using different surgical techniques, which lead to variable post-op results. All surgeries are usually done under general anesthesia. For the development and execution of this procedure, knowledge has been drawn from surgeries performed on male patients suffering from congenital disorders such as hypospadias and fibrous chordee.

Simple metoidioplasty or clitoral release

The clitoral release technique is the simplest type of procedure available, as well as the fastest and with less risks and complications, and the cheapest one. There is no urethral lengthening in this procedure, removing all the risks related to the modification of the lower urinary tract, but the patient won’t be able to void while standing.

The surgeon makes an incision on the skin surrounding the hypertrophic clitoris, on the lower side, and cuts off the ligament that secures the clitoris to the pubic bone (suspensory ligament) as well as cuts the clitoris crura, freeing the clitoris from all surrounding tissues and allowing for its extrusion and for visible erections to happen. Part of the labia minora and clitoral skin is excised and used as graft to make the clitoris larger in appearance.

It is still possible to undergo the urethral lengthening at a second time, but with a restricted range of possible surgical techniques available.

Full metoidioplasty

This technique is similar to the simple metoidioplasty but with the added step of the urethral lengthening. The urethral lengthening is performed by grafting tissues harvested from the oral mucosa or from the vaginal mucosa or from the labia minora. The urethra is then lengthened and moved forward up to the tip of the neopenis using a similar technique employed for the phalloplasty. Thanks to the urethral lengthening the patient can void while standing.

Ring flap metoidioplasty

This technique was developed in Japan by Dr. Ako Takamatsu.

There are some differences in the dissection of the clitoral chordee and suspensory ligament; the urethral lengthening presents some differences too: a ring flap is harvested from the vaginal mucosa and is used for the urethral lengthening.

Centurion metoidioplasty

The centurion technique for metoidioplasty was developed by US plastic surgeon Dr. Peter Raphael. The main difference is that it utilizes the round ligaments of the uterus to increase the girth of the neo-penis, including them into the shaft on both sides.

Post-op details

The metoidioplasty typically lasts 2-5 hours depending on what surgeries are performed with the metoidioplasty and on what technique is used.

If the urethral lengthening is performed during the procedure, a urinary catheter will be left in place for a period of 2-4 weeks, until the neo-urethra heals. A suprapubic cystostomy is also performed and kept until complete healing of the reconstructed urethra.

An antibiotic therapy will be prescribed and taken for about 7 days post-op.

It will be advised to use vacuum devices (negative pressure devices) for the mechanical traction of the tissues, to be used starting from the 4^th week post-op up for at least 6 months and up to a couple of years post-op, to maximize the results and lengthen the neo-penis during the healing process.

Final results depend upon the surgical technique employed, the experience of the surgeon and the anatomy of the patient and the grade of hypertrophy induced by the hormone replacement therapy. Final dimensions of the neo-penis are in the range of 2,5-10 cm, with an average length of about 5cm.

Metoidioplasty with urethral lengthening generally allows the patient to void while standing, although this is not guaranteed in 100% of the cases. Penetrative sexual intercourse is hardly achievable due to the dimensions of the neopenis with all the techniques available. However, a natural erection is possible.

The execution of a metoidioplasty does not preclude a future phalloplasty, but it will limit the surgical options.

Differences between metoidioplasty and phalloplasty

The main differences between metoidioplasty and phalloplasty are the following: metoidioplasty is an easier procedure to perform, it is less invasive, has a lower rate of post-op complications, and leads to better aesthetic results when compared to the phalloplasty that employs harvested tissues from the abdomen, thigh or forearm which leave a large conspicuous scar; moreover, the metoidioplasty is less expensive, is a faster procedure (3h in the OR vs 8-10h), it has a quicker recovery and requires less further surgeries (single stage procedure). Furthermore, the metoidioplasty does not require an erectile implant since it leaves intact the clitoris erectile tissue, but it won’t allow for penetrative sexual intercourse. Lastly, the metoidioplasty guarantees in almost the entirety of the cases the preservation of the erogenous and tactile sensation with the possibility to achieve clitoral orgasms also after the surgery.

Risks and Complications

As any medical or surgical therapy, the metoidioplasty carries some risks; among the risks there are the peri-operative bleeding, infections, difficulty in surgical wound closure, loss of sensation of the neo-penis, necrosis, hyperesthesia or paraesthesia of the surgical site, urethral strictures or fistulae, inability to void while standing.

The complications involving the neo-urethra might be manageable conservatively or might require corrective surgery.

Sources

• Metoidioplasty: a variant of phalloplasty in female transsexuals.
  SV Perovic, ML Djordjevic – BJU International, Nov 2003
• Metaidoioplasty: an alternative phalloplasty technique in transsexuals.
  Hage JJ – Plastic and Reconstructive Surgery Journal, Gen 1996
• Labial ring flap: a new flap for metaidoioplasty in female-to-male transsexuals.
  Takamatsu A, Harashina T – Journal of Plastic, Reconstructive and Aesthetic Surgery, Mar 2009
• Metoidioplasty: techniques and outcomes.
  ML Djordjevic, B Stojanovic, M Bizic – Translational Andrology and Urology Journal, Giu 2019
• Management of Gender Dysphoria – A Multidisciplinary Approach
  C Trombetta, G Liguori, M Bertolotto – Springer, 2015
• Principles of Transgender Medicine and Surgery – 2nd edition
  Ettner R, Monstrey S, Coleman E – Routledge 2016
• Sex Reassignment Surgery in the Female-to-Male Transsexual
  Monstrey SJ, Ceulemans P, Hoebeke P – Seminars in Plastic Surgery Journal, Ago 2011

Richard Troy

Medical Blogger committed to accuracy, I am passionate about delivering my readers critical insights into the medical field.
Former paramedic, instructor and medical school student.
You can read more about me in the dedicated section of the website.

www.medtravel.asia/about-richard-troy-medical-blogger/

The post FtM Bottom Surgery: metoidioplasty appeared first on MedTravel Asia.

Scrotoplasty is a broad term indicating any plastic or reconstructive surgery on the scrotum; it can be performed to repair defects or damages suffered to the scrotum or could be aimed towards complete scrotal reconstruction as in the case of transmen as one of the gender reassignment procedures. Scrotoplasty is also used to indicate aesthetic surgeries performed on cisgender males, such as those suffering from excessive scrotal laxity, in which case it is known as scrotal lift or scrotal rejuvenation.

In this blog post we will focus on the specific case of scrotoplasty for female to male transgender patients.

The scrotum is a thin elastic sack made of skin that contains the testicles and the epididymis and that is localized at the base of the penis. Its function is to house and protect the testes, to control their temperature and therefore allowing for optimal function of such organs and sperm production. From an aesthetical point of view, there’s great variability in shape and volume not only among different biological males, but also in the same male subject at different temperatures or different age.

In the case of FtM transgender patients, scrotoplasty has the goal of creating an aesthetically pleasing and accurate scrotum from other tissues of the patient, such as the labia majora.

At the beginning of the field of transgender medicine and surgery, a lot of focus was placed on procedures such as the phalloplasty for the treatment of gender dysphoria, but little importance was placed on scrotoplasty. During the years the patients started to be more demanding for what concerns aesthetic results, pushing surgeons to move forward and develop and improve new surgical techniques in the field of gender reassignment surgery; current surgical goals now include the creation of both a penis and a scrotum of natural appearance and aesthetically satisfactory.

Surgical techniques in scrotoplasty for transmen

There are several surgical techniques that can be performed for the realization of a scrotoplasty in the FtM transgender patient. Most of the times though, the surgeons choose to utilize the tissues harvested from the labia majora to reconstruct the scrotum: one of the main reasons for this, is that both evolve from the same embryonic structure during development; moreover, both of them have the same consistency and look, same color, have hair, and share the same nerve endings which respond to touch and erogenous stimulation.

Other surgical techniques employed in the past for the realization of the scrotoplasty were using flaps of tissue from the pubic, inguinal or thigh area. This technique though, is not easy to perform, carries more risks and leaves behind evident scars where the tissues are harvested which lead to patient dissatisfaction. Erogenous and tactile sensation are also poor and unsatisfying.

Therefore, there is general consensus on the use of labia majora flaps, sometimes employing tissue expanders to overcome the issue of the low volume of the surgically created neoscrotum; in these cases, after 6-12 months from the first step of scrotoplasty there is enough space for the testicular implants to be inserted.

Initially, surgery was performed by suturing the labia majora together by leaving them in the same place they are found in the biological female. This technique though, was aesthetically inaccurate and functionally inconvenient, with the neoscrotum being between the thighs; the results were still too similar to the female anatomy.

Later techniques were developed to address those issues and to reconstruct an aesthetically accurate scrotum in a more anterior position, in front of the thighs, as per the physiological anatomy of biological males. To achieve this result, the surgeon performs incisions in the lower part of the labia majora and also in the area of the pubic bone; the flaps obtained are then turned upwards and sutured to form a sack.

Scrotoplasty in the case of the FtM transgender patient is almost never performed as a standalone procedure, but it is usually part of a more complex surgery made of multiple procedures and known as sex reassignment surgery. Sometimes the bilateral hysterosalpingo-oophorectomy is performed previously, but often it is performed with the vaginectomy, the scrotoplasty, the phalloplasty or the metoidioplasty and the urethral lengthening as a single surgery for the genital reconstruction.

Risks and complications of scrotoplasty

Scrotoplasty doesn’t carry particular risks and is not subject to many complications. As any surgery there are risks, such as bleeding, bruising, surgical wound dehiscence (opening) and infection, but they are rare. Also, the need for a revision surgery is rare and the few complications that might arise are manageable conservatively.

The results obtained with the newer described technique for the scrotoplasty are satisfactory both aesthetically and functionally; the erogenous and tactile sensation satisfies almost the entirety of the patients.

Criteria for the scrotoplasty procedure

As part of a bundle of surgeries which includes also the metoidioplasty or phalloplasty, the vaginectomy and often the hysterosalpingo-oophorectomy, the Standards of Care 7^th edition of the World Professional Association for Transgender Care (WPATH) set some criteria or prerequisites to have access to this surgery.

• Persistent and well documented diagnosis of gender dysphoria
• In full possession of one’s faculties. Able to make a fully informed decision and to give consent for treatment.
• Age of majority in a given country.
• The absence of absolute medical contraindications (medical conditions which would make it too risky to perform the surgery).
• At least 12 continuous months of masculinizing hormone replacement therapy
• At least 12 continuous months of living in a gender role that is congruent with their gender identity.

These criteria are not applied to the patients undergoing a scrotoplasty procedure for reasons other than the treatment of gender dysphoria.

Sources

• Scrotal Reconstruction in Female-to-Male Transsexuals: A Novel Scrotoplasty.
  Selvaggi G, Hoebeke P, Ceulemans P, Hamdi M, Van Landuyt K, Blondeel P, De Cuypere G, Monstrey S – Plastic & Reconstructive Surgery Journal, Giu 2009
• Sex Reassignment Surgery in the Female-to-Male Transsexual
  Monstrey SJ, Ceulemans P, Hoebeke P – Seminars in Plastic Surgery Journal, Ago 2011
• Novel surgical techniques in female to male gender confirming surgery
  ML Djordjevic – Translational Andrology and Urology Journal, Ago 2018
• Management of Gender Dysphoria – A Multidisciplinary Approach
  C Trombetta, G Liguori, M Bertolotto – Springer, 2015

Richard Troy

Medical Blogger committed to accuracy, I am passionate about delivering my readers critical insights into the medical field.
Former paramedic, instructor and medical school student.
You can read more about me in the dedicated section of the website.

www.medtravel.asia/about-richard-troy-medical-blogger/

The post Scrotoplasty: scrotal reconstruction surgery in FtM transgender appeared first on MedTravel Asia.

The double subcutaneous mastectomy, also known as top surgery or chest reconstruction, is one of the main steps in female to male (FtM) gender transition. Transmen often consider it the most important surgery and the first one they undergo as it lets them live their own gender identity without the ambiguity caused by the shape of their chest. The mastectomy is considered a highly effective treatment for gender dysphoria and has a high post-op satisfaction rate not only for transgender patients but also for non-binary persons who find this surgery sufficient for their gender identity affirmation.

Generally speaking, a mastectomy is a surgery most often practiced in the oncologic field to excise breast tumors; there are several surgical techniques available and the procedure might remove different tissues based on the stage of the cancer. There could be excision of just the mammary gland, or the excision of areola and nipple too, up to the most serious cases which require the removal of all breast tissue plus the pectoralis major and minor muscles and axillary lymph node dissection (ALND or axillary lymphadenectomy).

Furthermore, a less radical form of mastectomy is practiced in few selected cases of patients with no cancer but with high risk of developing it due to their genetics and familiarity; in such cases it is called preventive or prophylactic mastectomy.

In this blog post though, we are going to talk about the specific case of the subcutaneous bilateral mastectomy in FtM transgender patients.

Surgical goals and different options in FtM Top Surgery

When performing a bilateral mastectomy or chest reconstruction, the surgeon will try to achieve the following five goals:

1. Reduce the breast tissue
2. Eliminate the intermammary cleft
3. Remove the excess skin
4. Reposition and resize the nipple and areola
5. Minimize the scars on the chest

The choice of the surgical technique will depend upon the anatomical characteristics of the patient, such as the breast size and elasticity of the skin, and from the knowledge and experience of the surgeon.

Hormone replacement therapy with testosterone has minimal and irrelevant effect on breast size in FtM transgenders. This is also one of the reasons why HRT is not a criterion for having access to this surgery unlike other SRS procedures.

The different surgical options for the bilateral subcutaneous mastectomy are the following:

• Semicircular incision or hemi-periareolar incision or Webster’s technique or keyhole technique. This technique is performed by making a small incision along the border of the lower half of the areola.
• Transareolar incision. This technique was developed by Prof. Ivo Pitanguy, the father of Plastic Surgery, and is performed by making a horizontal incision that splits in half both the areola and the nipple.
• Double concentric periareolar incision or concentric circular incision. This technique is performed by making two incisions: one along the outer border of the areola to form a circle and a second circular incision larger than the first one.
• Extended concentric circular incision. This technique is performed like the circular incision with the addition of the resection of triangles of tissue which have the base on the outer circular incision, and in number and dimension dependent on the breast size and the ptosis grade.
• Free nipple graft technique. This technique is performed by making an incision around the areola and harvesting a full-thickness graft of the nipple areola complex; this graft is preserved in saline solution while the mastectomy is performed; once the breast tissue is removed, the nipple area complex is repositioned in the most appropriate location.

The indications for these procedures, based on medical papers, advise the use of the semicircular technique when breast size is small (A cup) and there is mild ptosis (grade I) with good skin elasticity.

The transareolar incision is advised for patients with the same characteristics outlined above (A cup, mild ptosis and good skin elasticity) who also require a nipple reduction.

The concentric circular incision is indicated for patients with B cups and ptosis grade I or II and good skin elasticity; it is also indicated for smaller breast sizes with moderate skin elasticity.

The extended concentric circular incision is indicated for patients with C cups and ptosis grade II, with moderate skin elasticity.

Lastly, the free nipple graft technique is indicated for patients with large volume breasts and moderate to severe ptosis (grade II or III) especially when skin elasticity is scarce. This technique makes the mastectomy possible also in case of large volume breasts but has the disadvantage of both leaving scars which are more visible and of adding the risk of discoloration and loss of sensation to the nipple and areola.

In short, the larger the volume of the breast to excise and the larger the amount of skin to excise and the lower the elasticity of the skin of the patient, the longer will be the surgical incision in order to have satisfactory results which in turn will lead to a more visible scar.

Risks and complications of FtM mastectomy

Among the possible risks and complications for the bilateral subcutaneous mastectomy there are the intraoperative and post-operative bleeding, infection, hematomas and seromas that might require surgical evacuation (but that are prevented with drainages and bandages). It is also possible the formation abscesses or the partial necrosis of the nipple as well as the risk of asymmetries or deformities due to excess tissue in the pectoral area. There is often need for a second corrective surgery to improve the aesthetic result (20-25% of cases). Hence, it is good to discuss this topic with the surgeon before undergoing the procedure. Lastly there might be the risk of areola and nipple discoloration and loss of sensation depending on the technique employed.

It is also important to remind that undergoing this surgery doesn’t completely prevent the possibility of developing breast cancer. The nipple areola complex (NAC) and part of the breast tissue are left intact in place, leaving behind tissue that can potentially evolve into cancer.

Further information on bilateral mastectomy in female to male transgenders

The mastectomy can also be performed paired with the hysterosalpingo-oophorectomy, by employing two surgical teams; this is done to decrease the number of times the patient is subject to general anesthesia to complete the transition as well as to decrease the number of hours spent in the OR.

Scars are visible for at least 8-12 months, then they slowly fade. It is important to follow the surgeon’s advices to minimize scarring.

Surgery lasts on average 1-2 hours, but it depends from the technique used and the anatomical characteristics of the patient. During the first few days it is normal to have decreased sensation in the chest area. The patient is discharged 1-3 days post-op and the sutures are removed after about 5-10 days.  After that it is possible to get back to daily life, avoiding vigorous activities and heavy lifting. After about 4 weeks there should be no more restrictions.

The criteria to have access to the bilateral mastectomy as set by the Standards of Care 7^th edition of the World Professional Association for Transgender Health (WPATH) are the following:

• Persistent and well documented diagnosis of Gender Dysphoria by a mental health professional.
• In full possession of one’s faculties. Able to make a fully informed decision and to give consent for treatment.
• Age of majority in a given country.
• The absence of absolute medical contraindications (medical conditions which would make it too risky to perform the surgery).

There is no need to be taking the hormone replacement therapy with androgens to be eligible for this surgery.

These criteria do not apply for all those patients who undergo the mastectomy procedure for reasons other than the treatment of gender dysphoria.

Sources

• Transsexual Mastectomy: Selection of Appropriate Technique According to Breast Characteristics.
  Top H, Balta S – Balkan Medical Journal, Mar 2017
• Female-to-Male Gender Affirming Top Surgery: A Single Surgeon’s 15-Year Retrospective Review and Treatment Algorithm.
  McEvenue G, Xu FZ, Cai R, McLean H – Aesthetic Surgery Journal, Dic 2017
• Principles of Transgender Medicine and Surgery – 2nd edition
  Ettner R, Monstrey S, Coleman E – Routledge 2016
• Sex Reassignment Surgery in the Female-to-Male Transsexual
  Monstrey SJ, Ceulemans P, Hoebeke P – Seminars in Plastic Surgery, Ago 2011

Richard Troy

Medical Blogger committed to accuracy, I am passionate about delivering my readers critical insights into the medical field.
Former paramedic, instructor and medical school student.
You can read more about me in the dedicated section of the website.

www.medtravel.asia/about-richard-troy-medical-blogger/

The post FtM Top Surgery: Subcutaneous bilateral mastectomy for transgenders appeared first on MedTravel Asia.

The hysterosalpingo-oophorectomy is a type of surgery where the uterus, fallopian tubes and ovaries are excised from the patient. In general, the indication for this type of surgery or for a partial surgery may vary from the treatment of gynecologic neoplasia, fibromas, to endometriosis, to uterine prolapse. Hysterectomy alone is a common surgery and the most common surgery in the gynecologic field after the cesarean section, with over 600,000 surgeries performed every year in the USA alone.

Based on the clinical presentation, it might be sufficient to remove only some, or part of the organs and the surgeries are known as:

• Hysterectomy, which involves the removal of the whole uterus
• Salpingo-oophorectomy, which is the removal of an ovary and its fallopian tube on one side
• Partial Hysterectomy, known also as subtotal hysterectomy or supracervical hysterectomy which is the removal of the uterus leaving the cervix intact in place.

All of these surgeries cause irreversible infertility.

In this blog post we will talk about one specific case: hysterosalpingo-oophorectomy, the removal of both ovaries, fallopian tubes and the whole uterus in the specific case of the FtM transgender patient in the context of sex reassignment surgery (SRS).

Why having the hysterosalpingo-oophorectomy in FtM SRS?

The main and obvious reason for which transgender males chose this surgery is to remove the sexual organs of the gender assigned at birth and not congruent with their gender identity, which is a cause of dysphoria, meaning a negative mental state which can result in depression, anxiety, and other psychiatric conditions. In this specific case it is known as gender dysphoria.

Moreover, hormone replacement therapy (HRT) with testosterone causes modifications in the tissues and it may lead to developing symptoms similar to PCOS (polycystic ovary syndrome) and endometrial hyperplasia with risk of developing tumors of the endometrium and of the ovaries. Being the FtM transgender population limited in numbers with most patient opting early for this type of surgery there are no definitive long-term studies on the effects that HRT can have on the uterus and ovaries. Hence, the previous is just a supposition based on the data currently available.

Another reason to undergo this surgery is that once you remove the female reproductive organs, there is no more estrogen production by the ovaries, which allows for a lower dose of testosterone to be taken for transitioning.

Fourth reason to choose the bilateral hysterosalpingo-oophorectomy in the FtM transitioning is that once they undergo this surgery, the patient does not have to worry anymore about having regular gynecological examinations nor about performing pap smear tests. These are often crucial factors in the decision to undergo this surgery since the transgender man generally feels uncomfortable or embarrassment due to having to undergo such examinations and getting rid of this duty often relieves the patient and eliminates a source of bad feelings. Furthermore, the removal of the female reproductive organs ends any chronic or possible future gynecologic issue, from menstruations, to abdominal cramps, to bleeding and pain.

It’s good to reiterate though that this surgery leads to the definitive, irreversible inability to bear children and should be chosen only by the transgender men who do not wish to maintain their fertility. Cryopreservation of the oocytes is an option to consider for those who do not want to completely lose the ability to procreate and should be discussed with the treating physicians.

Types of hysterectomy and salpingo-oophorectomy: the different options

There are several different surgical approaches for the hysterectomy. The choice depends upon several factors: the anatomical characteristics of the patient, the surgeon’s knowledge and experience, whether or not other surgical procedures are performed at the same time such as the vaginectomy, metoidioplasty or phalloplasty, and from the specific reason the patient is undergoing this surgery.

1. Total abdominal (laparotomic) hysterosalpingo-oophorectomy
2. Total laparoscopic hysterosalpingo-oophorectomy
3. Total Vaginal hysterosalpingo-oophorectomy
4. Laparoscopically assisted vaginal hysterosalpingo-oophorectomy
5. Total robotic hysterosalpingo-oophorectomy

1. Total abdominal (laparotomic) hysterosalpingo-oophorectomy

The laparotomic technique, also known as TAH, is the most traditional and invasive technique available, but sometimes it is a necessary choice and it is advisable over other surgical techniques, such as in the case of large and widespread tumors that need to be excised. It requires a long incision between 12 and 30 cm long (5-12 inches) that can be made horizontally or vertically based on variables about the surgery and the patient. The laparotomic approach might also be required when difficulties emerge during a laparoscopic surgery. The surgery lasts about 1-3 hours and it is highly invasive, requiring an inpatient stay at the hospital of about 5 days and 6 to 8 weeks before full recovery and going back to all regular life activities without restrictions. The scar will be visible, but surgeons usually try to perform an horizontal incision right over the pubic line (Pfannenstiel incision); although visible and long, this way it should be easily concealable in public being covered by clothes or even by swimming suits.

2. Total laparoscopic hysterosalpingo-oophorectomy

The laparoscopic approach, known also as TLH, is usually the preferred and first choice for the FtM transgender patients.

The surgery requires general anesthesia. An incision long about 1 cm is made at the belly button, to minimize the aesthetic damage and make the scar almost invisible; through that incision the fiber optic is inserted, allowing for the visualization of the abdominal organs. To have a better visual, the abdomen is inflated with carbon dioxide (CO2). Three more incisions, about 0,5cm long, are then made: one suprapubic, on the median line of the abdomen which will be covered by pubic hair, and two suprailiac incisions, one on each side, right above the iliac crests and often made asymmetrically to make it less likely for a lay person to recognize them as obvious surgical scars. These incisions are where the surgical instruments are inserted and from them all anatomical structures, dissected first, will be extracted.

By using this surgical technique, blood loss is halved when compared to the laparotomic approach. Surgery lasts 1-3 hours and requires an in-hospital stay of 1-2 days. Post-op recovery is faster too with this technique, averaging 2-4 weeks before being able to go back to everyday activities.

3. Total Vaginal hysterosalpingo-oophorectomy

The total vaginal hysterosalpingo-oophorectomy, known also as TVH, involves the extraction of the reproductive organs through an incision made in the vagina. The whole surgery is carried out through the vaginal incision, thus leaving no obvious scar and having a better aesthetic result than the previous two techniques. The absence of abdominal incisions though, makes it harder to access the abdominal cavity for the surgeon, who might not be able to carry out the surgery in the presence of abdominal adhesions, or who might not be able to visualize and examine the tissues in the presence of endometriosis; this approach also increases the risk of inadvertent internal injuries and makes it harder to extract the ovaries, with higher chances of post-op complications. Being a surgery completely carried out through the vagina, it is easier to perform in the presence of vaginal laxity, which is common among multiparous women (those who had multiple pregnancies), but it is rarely the case of FtM transgender men who in almost all cases are nulliparous.

This surgery lasts about 1-3 hours with an in-hospital stay of about 1-5 days. Post-op recovery is about 6-8 weeks before being able to get back to everyday activities without restrictions.

4. Laparoscopically assisted vaginal hysterosalpingo-oophorectomy

The laparoscopically assisted vaginal hysterosalpingo-oophorectomy, known also as LAVH, combines two of the above surgical approaches which are TVH and TLH. The fiber optic and the surgical instruments are inserted through small abdominal incisions, as in TLH, but the uterus and the other organs are removed through an incision made in the vagina as in TVH.

Surgery lasts about 1-3 hours and requires an in-hospital stay of about 1-2 days. Post-op recovery is about 4 weeks long before being able to get back to everyday activities without any restriction.

5. Total robotic hysterosalpingo-oophorectomy

This procedure is similar to TLH, with the difference of being carried out with a surgical robot. It is a minimally invasive technique and the surgeon remotely controls the robot, instead of directly moving the instruments. This allows for greater precision of movements and a more precise execution of the surgery, which would not be possible with just human hands and arms. Surgery lasts a bit longer than with traditional methods, about 2-4 hours in total and has an higher cost; it requires 5 incisions instead of 3 or 4, and the incisions will be 8-12mm long instead of 5mm. As of today there is no clear evidence of the superiority of this technique when compared to TLH, reason for which medical associations such as the American College of Obstetricians and Gynecologists (ACOG) don’t advise this procedure, preferring TLH instead.

Post-operative care

After surgery the patient might feel a little disoriented, this is a common and temporary side effect of anesthesia. Before surgery a urinary catheter will be inserted as well as one or more venous catheters for the IV administration of fluids and medications. Venous thrombosis prevention systems will be used too, such as compression stockings or an intermittent pneumatic compression device. Early mobilization is encouraged, so the patient will be helped to get up from bed and move around early with caution for a faster recovery.

Pain is subjective but will be controlled with medications; it will be caused by the surgical incisions, but it is possible to feel pain or discomfort at the level of the shoulder or diaphragm due to the distention caused by the CO2 when inflating the abdomen. Third and last cause of discomfort will be the bowels, with possible cramps when it will get back to its normal activity, about 24-36 hours post-op.

Risks and complications of the hysterosalpingo-oophorectomy

As any other surgery this procedure carries some variable risks based on the characteristics of the patient and the technique used by the surgeon. Among these, there are the risk of bleeding, infection, risks related to the administration of anesthesia and deep vein thrombosis. Among the possible complications there are the development of irritable bowel syndrome (IBS), incontinence, accidental damage to the intestine or urethra, formation of abdominal adhesions, chronic pain and prolapse.

Criteria for hysterosalpingo-oophorectomy in the female to male transition

The Standards of Care 7^th edition of the World Professional Association for Transgender Health (WPATH) set the following criteria for accessing this type of surgery:

• Persistent and well documented diagnosis of gender dysphoria
• In full possession of one’s faculties. Able to make a fully informed decision and to give consent for treatment.
• Age of majority in a given country.
• The absence of absolute medical contraindications (medical conditions which would make it too risky to perform the surgery).
• 12 continuous months of hormone replacement therapy with testosterone, unless not clinically indicated for the patient

These criteria do not apply to patients having these surgical interventions for reasons other than gender dysphoria.

The reason for which hormone replacement therapy is set as a criterion is to allow the patient to experience testosterone and the suppression of estrogen in a reversible way, before committing to invasive and irreversible surgery.

Sources

• World Professional Association for Transgender Health Standards of Care. 7^th
• Transgender Medicine: A Multidisciplinary Approach.
  Leonid Poretsky, Wylie C. Hembree. Springer, 2019
• Principles of Transgender Medicine and Surgery, second edition.
  Randi Ettner, Stan Monstrey, Eli Coleman. Routledge, 2016.
• Management of Gender Dysphoria
  Carlo Trombetta, Giovanni Liguori, Michele Bertolotto. Springer, 2015
• Complication Rates and Outcomes After Hysterectomy in Transgender Men.
  Bretschneider CE, Sheyn D, Pollard R, Ferrando CA – Obstetrics & Gynecology Journal, Nov 2018
• Total Laparoscopic Hysterectomy for Female-to-Male Transsexuals
  O’Hanlan KA, Dibble SL, Young-Spint M – Obstetrics & Gynecology Journal, Nov 2007

Richard Troy

Medical Blogger committed to accuracy, I am passionate about delivering my readers critical insights into the medical field.
Former paramedic, instructor and medical school student.
You can read more about me in the dedicated section of the website.

www.medtravel.asia/about-richard-troy-medical-blogger/

The post Hyterosalpingo-oophorectomy: surgical removal of the uterus, fallopian tubes and ovaries in FtM transgender patients appeared first on MedTravel Asia.

The vaginectomy, also known as vaginal colpectomy, is one the of the surgical procedures performed in female to male (FtM) sex reassignment surgery (SRS).

The surgery consists of two steps:

• Colpectomy, which is the excision and removal of the vaginal lining
• Colpocleisis, which is the surgical closure of the vagina by applying sutures throughout the vaginal canal

The vaginectomy is generally part of a set of procedures and not performed by itself; such procedures are the hysterosalpingo-oophorectomy, the metoidioplasty or the phalloplasty with urethral lengthening and the scrotoplasty.

Types of Surgery

Generally speaking, and not in the specific case of sex reassignment surgery for transmen, there are different procedures known as vaginectomy:

• Partial Vaginectomy, when only part of the vaginal tissues are excised. It is a type of surgery performed in oncological patients when the tumors are small and localized, affecting only the mucous membrane of the vagina.
• Total Vaginectomy, when all vaginal tissues are excised. It can be performed in cancer patients when the tumor is not localized, or in gynecological patients suffering from uterine or vaginal prolapse, or in transgender patients during their transition from female to male and where part of the anterior tissues close to the urethra will be spared to perform the urethral lengthening.
• Radical Vaginectomy, when all vaginal and paravaginal tissues (surrounding the vagina) are removed. It is an invasive and radical surgery usually performed in case of advanced stage cancer.

Reasons for vaginectomy in transgender men

The most obvious reason why transmen undergo a vaginectomy is clearly that of removing the female sexual organs since they are not congruent with their gender identity and might cause gender dysphoria.

Another reason why they seek this surgery is that by removing all vaginal tissues there is no more need to undergo periodic gynecological examinations and pap tests, as well as there are no more secretions produced by the vaginal lining. Moreover, hormone replacement therapy with testosterone leads to atrophic changes of the mucous membrane of the vagina which can cause itching, burning sensation, discomfort and other issues; by undergoing the vaginectomy all these symptoms will disappear.

In addition, from published medical papers, it appears that undergoing a vaginectomy while also performing a phalloplasty allows for the use of vascularized vaginal vestibule tissues to perform the urethral lengthening which results in a lower rate of complications such as fistulas and urethral strictures which need corrective surgery. Thanks to the urethroplasty, the patient can urinate while standing which would otherwise not be possible.

The vaginectomy procedure

Vaginectomy is an invasive or major surgery which requires an inpatient hospital stay.

Surgery is performed under general anesthesia and is usually done in combination with other procedures such as the hysterosalpingo-oophorectomy and the genital reconstruction by either phalloplasty or metoidioplasty with urethral lengthening and the scrotoplasty.

The patient lies in a seated position similar to the delivery or childbirth position, to expose the vaginal and perineal regions. Pelvic region is examined, and the urinary catheter is inserted. An incision is made around the vagina reaching the pubocervical fascia. The surgeon then separates the mucosa from the vaginal walls. Pudendal artery is identified, clamped and ligated. The surgeon then proceeds with the dissection of the vagina below the urethra and the bladder, paying attention not to damage any of the many blood vessels present in that region. The bladder is separated from the vaginal wall, as well as the ureters, the cervix and the rectum. At this point it is possible to extract the vagina without damaging any of the surrounding structures. Pelvic floor is then reconstructed to avoid post-op complications such as rectocele, or herniation of the rectum into the vaginal region, and cystocele which is the prolapse of the bladder into the vaginal region. Lastly, sutures are placed to close the vaginal canal and the vaginal opening.

Post-op information

Time of recovery varies depending on the surgeries performed with the vaginectomy or if it was performed as a standalone procedure. In general, an in-hospital stay of one week will be required and there will be a surgical drain in place for the first few days post-op. After about two weeks the pain or discomfort felt will be considerably lower and will be possible to get back to work and to daily life; pain and discomfort in the acute phase will anyway be controlled with medications prescribed by the medical team. There will be some initial restrictions in the activities allowed: physical exercise, especially when intense, won’t be allowed as well as cycling, swimming and sexual intercourse.

Risks and complication of vaginectomy

Vaginectomy is an invasive surgical procedure performed under general anesthesia. As such, it carries risks and possible complications, among which there are perioperative and post-op bleeding, localized infection or sepsis, urinary fistula, rectal disfunctions such as constipation, deep vein thrombosis (DVT), pain, fever and damage to the lower urinary tract.

Criteria for vaginectomy in female to male sex reassignment

The Standards of Care 7^th edition of the World Professional Association for Transgender Health (WPATH) set criteria to be eligible for the vaginectomy in the transition process from female to male:

• Persistent and well documented diagnosis of gender dysphoria
• In full possession of one’s faculties. Able to make a fully informed decision and to give consent for treatment.
• Age of majority in a given country.
• The absence of absolute medical contraindications (medical conditions which would make it too risky to perform the surgery).
• At least 12 continuous months of hormone replacement therapy with androgens

These criteria are not applied to the patients who undergo a vaginectomy for reasons and indications other than the treatment of gender dysphoria.

Sources

• Principles of Transgender Medicine and Surgery – 2^nd edition
  Ettner R, Monstrey S, Coleman E – Routledge 2016
• Transgender Medicine – A multidisciplinary Approach
  Poretsky L, Hembree WC – Springer 2019
• Phalloplasty with Urethral Lengthening: Addition of a Vascularized Bulbospongiosus Flap from Vaginectomy Reduces Postoperative Urethral Complications
  Massie JP, Morrison SD, Wilson SC, Crane CN, Chen ML – Plastic & Reconstructive Surgery Journal, Ott 2017
• The World Professional Association for Transgender Health Standards of Care 7^th Ed.
• Sex Reassignment Surgery in the Female-to-Male Transsexual
  SJ Monstrey, P Ceulemans, P Hoebeke – Seminars in Plastic Surgery Journal, Ago 2011
• Outcome and Risk Factors for Vaginectomy in Female-to-Male Transsexuals
  M Spilotros, DJ Ralph, N Christopher – Institute of Urology (London) – World Meeting on Sexual Medicine 2013

Richard Troy

Medical Blogger committed to accuracy, I am passionate about delivering my readers critical insights into the medical field.
Former paramedic, instructor and medical school student.
You can read more about me in the dedicated section of the website.

www.medtravel.asia/about-richard-troy-medical-blogger/

The post FtM SRS: Vaginectomy procedure in transgender men appeared first on MedTravel Asia.

Face masculinization surgery is a set of surgical procedures with the goal of modifying the facial features of the patient and make them more masculine; these procedures are requested both by FtM transgender patients and by cisgender men who desire stronger male facial features.

Biological males and females express a different facial anatomy in particular for what concerns the mandibular angle and the jaw, the chin, the forehead, the cheekbones, the nose, the hairline and the facial hair (beard, mustache and eyebrows) plus the thyroid cartilage or Adam’s apple that although not being technically on the face is often considered among the facial features in facial masculinization surgery. A more extensive list of the differences between male and female facial anatomy can be found in the facial feminization surgery article.

In social settings and when we first meet someone, the face is the first part of the body we look at and it is from the face that we deduce among the many things also the gender identity. To avoid a wrong identification, incongruent with an individual’s gender identity (this applies to cisgender males with androgynous features too) and the consequences that this can have psychologically, some individuals decide to undergo facial masculinization surgery.

These procedures are not as commonly performed as the facial feminization procedures, but still they are performed routinely in specialized craniofacial and maxillofacial plastic surgery centers. They are optional surgeries, often objectively not needed, as the FtM transgender patient undergoes a masculinization process once hormone replacement therapy with testosterone is started, with results which are generally considered satisfactory and sufficient.

The most commonly requested and performed facial masculinization procedures are the following:

• Eyebrow lowering and thickening surgery
• Forehead augmentation and lengthening surgery
• Augmentation rhinoplasty
• Jaw and mandibular angle enhancement
• Chin augmentation
• Adam’s apple augmentation
• Cheek remodeling
• Beard and mustache transplant

Forehead and eyebrows masculinization procedures

The forehead is a considerable area of the face, covering it for about 30-35% (the upper third); modifying its characteristics leads to a substantial change in facial aesthetics.

The goals of forehead masculinization are lengthening it, which means increasing the distance between the eyebrows and the hairline,  widening it, and creating the typical protrusions in the frontal sinuses region known as frontal bossing as well as the protrusion at the level of the upper orbital rims known as supraorbital ridge.

These changes can be done singularly or as a set of procedures depending of the expectations of the patient. Some changes can also be obtained non-surgically as minimally invasive procedures by injecting soft-tissue fillers or with an autologous fat graft, while others might require the use of tissue expanders, synthetic implants or autologous bone grafts, always depending on the desired results and expectations.

Laser hair removal can also be employed to raise the hairline and shaping it following the typical male aesthetic (M-shaped hairline).

The eyebrows can be lowered both to lengthen the forehead and to match the typical male feature of having the eyebrows below the supraorbital rim which are also straight instead of arcuated. Male eyebrows are also thicker than female ones; it is possible to perform a transplant by harvesting hair with similar characteristics to the eyebrows (monobulbar follicular units, thick hair, marked follicular inclination) from the occipital region by using the FUE transplant technique.

Augmentation rhinoplasty

Men tend to have a longer and larger nose, which is also more projected (sticks out more from the face) when compared to women ones. It is possible to modify these features by using synthetic implants, or autologous tissue such as rib cartilage or in some cases also by injecting fillers, which is a minimally invasive technique capable of obtaining satisfactory results depending on the patient’s expectations and their unique anatomy.

Jawbone and mandibular angle reshaping

The typical male jaw is squared with a well pronounced mandibular angle as opposed to the more harmonious jaw and slender face of the female population.

To change such features, it is possible to use implants placed through incisions within the oral cavity to avoid visible scars and then secured with metal screws. Another technique uses autologous bone tissue harvested from the iliac crest or from the skull which is then inserted in a sagittal cut of the mandibular angle bone tissue, between the external part (periosteum) and the spongy bone; this placement doesn’t allow for the resorption of the bone graft as it would happen if placed between the masseter muscle and the periosteum.

Genioplasty – Chin reshaping surgery

The male chin is longer, larger and pronounced than the female one. An anterior prominence is also common among males.

The augmentation of the vertical dimension is hardly achievable with an implant; the preferred technique in this case is the osteotomy, or cut of the bone, and then reshaping of the chin by repositioning the pieces of bone tissue, using surgical screws, plates or wire. The empty spaces that could result by this reshaping process can be filled with tissue fillers. Anyway, it is possible to contour the chin also by placing a synthetic implant.

Genioplasty is often performed jointly with the jawbone reshaping in order to obtain a more natural and harmonious result of the whole lower third of the face.

Thyroid cartilage enhancement – Adam’s Apple augmentation

One of the most obvious and distinctive features in biological male and female aesthetics is the presence of a more or less pronounced thyroid cartilage.

It is possible to surgically recreate this typical male feature by placing an autologous graft harvested from the patient’s rib cartilage; this graft is then properly shaped and implanted over the native thyroid cartilage of the patient enhancing the Adam’s apple. Not only it will be more pronounced and anteriorly projected, but it will also follow the natural movements of the thyroid cartilage sliding upwards and downwards when swallowing.

Malarplasty – Cheekbones contouring

Male cheekbones are more chiseled and flatter compared to female ones. Based on the anatomical characteristics and expectations of the patient it will be possible to reshape the cheekbones by using implants, or by injecting fillers or autologous fat, or by reshaping/reducing the fat tissue and remodeling the underlying bone tissue.

Beard and hair transplant

The techniques employed for a hair or beard transplant in a FtM transgender patient are no different than those normally employed for the very common FUE hair transplant. The same technique can also be used to transplant body hair, for example in the chest, abdomen and pubic region. Hormone replacement therapy with androgens generally increases the amount of body hair as well as their thickness but could also cause the typical male hair thinning known as androgenic alopecia.

Criteria for facial masculinization procedures and pre-op procedures

Contrary to other surgeries which are part of the FtM transition such as the mastectomy or the gender reassignment procedure, the World Professional Association for Transgender Care (WPATH) did not set any criterion for facial masculinization surgery. Hence, hormone replacement therapy, or a gender dysphoria diagnosis or having lived in the gender role for at least 1 year are not required to have access to such procedures.

Still, there are some criterion like for any other plastic surgery procedure:

• Age of majority in a given country.
• In full possession of one’s faculties. Able to make a fully informed decision and to give consent for treatment.
• The absence of absolute medical contraindications (medical conditions which would make it too risky to perform the surgery).

Before surgery there will be a consultation with the surgeon who will prescribe pre-op exams such as lab tests, anesthesiology consultation, imaging (X-Rays or CT Scan), etc.

You might be required to take or stop taking some medications. It is highly advised to quit smoking and aspirin or other blood thinning medications are to be avoided in the week prior to surgery.

Hormone replacement therapy with androgens, although not being a prerequisite, is advised as it is capable by itself to cause structural changes in the bone structure as well as in tissue composition, giving a more masculine look. For an optimal aesthetic result it is usually advised to wait for the modifications induced by testosterone before undergoing invasive surgeries.

Complications and risks of facial masculinization surgery

The surgeon will take care of explaining in detail all the risks and possible complications resulting from the specific facial masculinization procedures the patient is undergoing, which also depend on the technique used, the materials and the anatomy of the patient.

Among the risks there are bleeding, infection, wound healing issues, prolonged swelling, bone healing issues, implant migration, loss of hair where the incisions are performed and the anesthesiologic risks.

Sources

• ASPS – American Society of Plastic Surgeons
• First Female-to-Male Facial Confirmation Surgery with Description of a New Procedure for Masculinization of the Thyroid Cartilage (Adam’s Apple)
  Deschamps-Braly JC, Sacher CL, Fick J, Ousterhout DK – Plastic and Reconstructive Surgery Journal, Apr 2017
• Dr. Paul Tessier and facial skeletal masculinization.
  Ousterhout DK – Annals of Plastic Surgery Journal – Dic 2011
• Gender-confirming facial surgery: considerations on the masculinity and femininity of faces.
  Hage JJ, Becking AG, de Graaf FH, Tuinzing DB. – Plastic and Reconstructive Surgery Journal, Giu 1997
• Principles of Transgender Medicine and Surgery – 2^nd edition
  Ettner R, Monstrey S, Coleman E – Routledge 2016
• Transgender Medicine – A multidisciplinary Approach
  Poretsky L, Hembree WC – Springer 2019

Richard Troy

Medical Blogger committed to accuracy, I am passionate about delivering my readers critical insights into the medical field.
Former paramedic, instructor and medical school student.
You can read more about me in the dedicated section of the website.

www.medtravel.asia/about-richard-troy-medical-blogger/

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